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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198204376
Report Date: 05/19/2023
Date Signed: 05/19/2023 06:06:02 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/10/2023 and conducted by Evaluator Bonnie Tao
COMPLAINT CONTROL NUMBER: 28-AS-20230510153821
FACILITY NAME:MOUNTAIN VIEW COTTAGES - IVFACILITY NUMBER:
198204376
ADMINISTRATOR:TRUPTI MODYFACILITY TYPE:
740
ADDRESS:21027 WEST COVINA BLVD.TELEPHONE:
(626) 966-4842
CITY:COVINASTATE: CAZIP CODE:
91724
CAPACITY:6CENSUS: 4DATE:
05/19/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jasbindar Singh, Administrator
Staff#2		TIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Facility hired uncleared adults to work in the facility.
Staff are not ensuring that facility is free from pests.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tao conducted unannounced complaint investigation for the allegations listed above. During today’s visit, LPA met with Staff#2 upon arrival at the facility. Administrator, Jasbindar Singh joined the visit later in the afternoon. LPA explained the purpose of today's visit regarding the above-mentioned allegations.

The investigation consisted of the following: interviews of staff from Staff #1 (S1) through Staff #3 (S3); interviews of residents from resident#1 (R1) through resident #3 (R3); attempted to interview resident#4 (R4) and family member of a former resident; reviewed facility records, and a facility tour. LPA obtained copies of the staff and resident rosters, facility files and documents with relevant information.
The investigation revealed the following:
In regard of the allegation, “facility hired uncleared adults to work in the facility,” it was alleged that facility hired adults who had not been fingerprint cleared and associated with the facility.
(-continued in LIC 9099 C-)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 28-AS-20230510153821
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/19/2023
NARRATIVE
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Three (3) out of four (4) residents interviewed stated could not corroborate the allegation. One resident declined to be interviewed. Two (2) out of three (3) staff interviewed denied the allegation. Administrator explained there was no uncleared or undocumented adults working in the facility but there was one unassociated staff. Per record review, Staff#2, who is cleared, but has not been associated with the facility is working there. Therefore, the investigation revealed that facility had an un-associated staff working in the facility.

In regard of the allegation, “staff are not ensuring that facility is free from pests,” it was alleged facility had cockroaches. Two (2) out of three (3) residents interviewed revealed they saw live cockroaches in their room in the facility. All three (3) staff interviewed stated the facility had cockroaches. Per facility tour, LPA observed live cockroaches in the kitchen and dead cockroaches in residents’ rooms. Administrator explained facility had pest control services for cockroaches on 4/14/23 and additional pest control services were scheduled until pest issue cleared. Therefore, the facility has pests’ issue.

Based on review of documents and interviews conducted, the preponderance of evidence standard has been met, therefore the above two allegations are found to be SUBSTANTIATED.

Deficiencies are being cited according to California Code of Regulations, Title 22, Division 6, Chapter 1. See LIC 9099D. An immediate civil penalty was cited for having un-associated staff working in the facility.

An exit interview was conducted with Administrator. A hard copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/10/2023 and conducted by Evaluator Bonnie Tao
COMPLAINT CONTROL NUMBER: 28-AS-20230510153821

FACILITY NAME:MOUNTAIN VIEW COTTAGES - IVFACILITY NUMBER:
198204376
ADMINISTRATOR:TRUPTI MODYFACILITY TYPE:
740
ADDRESS:21027 WEST COVINA BLVD.TELEPHONE:
(626) 966-4842
CITY:COVINASTATE: CAZIP CODE:
91724
CAPACITY:6CENSUS: 4DATE:
05/19/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jasbindar Singh, Administrator
Staff#2		TIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility did not follow general food service requirements.
Staff yell at resident(s) in care.
INVESTIGATION FINDINGS:
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2
3
4
5
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7
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13
Licensing Program Analyst (LPA) Tao conducted unannounced complaint investigation for the allegations listed above. During today’s visit, LPA met with Staff#2 upon arrival at the facility. Administrator, Jasbindar Singh joined the visit later in the afternoon. LPA explained the purpose of today's visit regarding the above-mentioned allegations.

The investigation consisted of the following: interviews of staff from Staff #1 (S1) through Staff #3 (S3); interviews of residents from resident#1 (R1) through resident #3 (R3); attempted to interview resident#4 (R4) and family member of a former resident; reviewed facility records, and a facility tour. LPA obtained copies of the staff and resident rosters, facility files and documents with relevant information.

The investigation revealed the following:
In regard of the allegation, “Facility did not follow general food service requirements," it was alleged that residents were not fed adequately. (-continued in LIC 9099 C-)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20230510153821
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/19/2023
NARRATIVE
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Three (3) out of four (4) residents interviewed stated could not corroborate the allegation. One resident declined to be interviewed. All three (3) staff who were interviewed denied the allegation. Per file review, facility had weekly food menu and posted at the kitchen. Residents interviews revealed that staff followed food menu and provide various of food. All three (3) staff who were interviewed denied the allegation. LPA tour the kitchen, a food menu was posted in the kitchen and refrigerator had 2 days of perishable food supplies with variety. LPA observed residents during dinner time, residents got 2 serves of fruit, 8 oz of meat, 2 serves of vegetable and 1.5 cup of pasta on their plates. Therefore, there is not preponderance evidence to prove the facility failed to provide general food services.

In regard of the allegation, “staff yell at resident(s) in care, it was alleged that staff#2 (S2) yelled at residents. Three (3) out of four (4) residents interviewed stated could not corroborate the allegation. One resident declined to be interviewed. Residents interviewed reveal that staff did not yell at residents. All three (3) staff who were interviewed denied the allegation. Staff interviews revealed facility had a policy and in service training to ensure residents’ right and being treat with respect. Therefore, there is not preponderance evidence to prove staff yell at residents.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore, the allegations is UNSUBSTANTIATED.

An exit interview was conducted with Administrator. A hard copy of the reports were provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20230510153821
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/20/2023
Section Cited
CCR
87355(e)(2)
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Criminal Record Clearance. ... prior to working, residing or volunteering in a licensed facility: (1)Request a transfer of a criminal record clearance.

This requirement is not met as evidenced by:
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The facility will ensure that a criminal record clearance/exemption of all staff had been transferred and associated to the facility prior to working or being present at the facility.
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Facility was unable to provide evidence that a criminal record transfer was requested for staff Yoseph Husada. Staff#2.

Based on observation and file review, it poses/posed a immediate health, safety or personal rights risk to persons in care.
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Administrator would submit evidence to Licensing that a criminal record clearance transfer and association of staff Yoseph Husada by POC due date on 5/20/23.
Type B
06/16/2023
Section Cited
CCR
87303(a)
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The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
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Administrator agreed to hire a pest control company to evaluate insects/pest issues and will hire a pest control company for pest control treatment. Administrator would submit proof of pest control service invoice by POC due date.
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Based on observation, LPA observed cockroaches in the kitchen cabinets; which poses/posed a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5