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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204376
Report Date: 11/10/2022
Date Signed: 11/10/2022 11:48:15 AM


Document Has Been Signed on 11/10/2022 11:48 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:MOUNTAIN VIEW COTTAGES - IVFACILITY NUMBER:
198204376
ADMINISTRATOR:TRUPTI MODYFACILITY TYPE:
740
ADDRESS:21027 COVINA BLVD.TELEPHONE:
(626) 966-4842
CITY:COVINASTATE: CAZIP CODE:
91724
CAPACITY:6CENSUS: 4DATE:
11/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Jasbindar Singh, Administrator TIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met Jasbindar Singh, Administrator and explained the purpose of the visit. The facility has a capacity of six (6) to serve residents from age 60 and above which may have six (6) non-ambulatory and approved for four (4) hospice waiver. Two (2) residents are on hospice. Annual fee is current.

The visit consisted of: the infection control domain tool was used, interviews were conducted, a tour of the facility was conducted, food supply was reviewed, and medications were reviewed.

This facility is a single story house located in a residential neighborhood in Covina. The facility consisted of five (5) bedrooms which including three (3) resident bedrooms and two (2) staff bedrooms, two (2) bathrooms, office, living room, dining room, kitchen, and back yard.

The kitchen was clean and has maintained the required two (2) days perishable and seven (7) days non- perishable. Each resident's bedroom had a dresser, chair and closet space available. Adequate linen and personal hygiene supply were observed. Bathrooms inspected and were clean, operable, with the required grab bars and non-skid materials in the shower. Hot water temperature was measured at 114.9 degrees Fahrenheit which was within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies were observed.

(-continued in LIC 809 C-)
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:
DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: MOUNTAIN VIEW COTTAGES - IV
FACILITY NUMBER: 198204376
VISIT DATE: 11/10/2022
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Smoke detectors and carbon monoxide detectors were operable. Fire extinguishers were fully charged and last service was on 10/20/22. Auditory devices were operable. Fire drill was conducted on 9/29/22. Administrator certificate had an expiration date on 4/11/2023. The first aid kit was fully stocked. Mandated documents and signages were posted in common areas. The outdoor activity area had a shaded patio with ample seating. Medication is centrally stored and current. Resident records were stored in a locked storage room and inaccessible to residents. There are no pools and bodies of water on the premises. There were no firearms on the premises. Facility maintained a comfortable temperature of 73 degrees Fahrenheit for residents.

No deficiencies cited per California Code of Regulations, Title 22.

An exit interview was conducted. This report is discussed and provided to facility Administrator, whose signature on this form confirm receipt of these documents.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022
LIC809 (FAS) - (06/04)
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