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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204376
Report Date: 11/26/2023
Date Signed: 11/26/2023 04:08:34 PM


Document Has Been Signed on 11/26/2023 04:08 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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 WEST COVINA BLVD.TELEPHONE:
(626) 966-4842
CITY:COVINASTATE: CAZIP CODE:
91724
CAPACITY:6CENSUS: 4DATE:
11/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jennifer DiscipuloTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required 1-year Visit on 11/26//2023.
LPA was met by Administrator Jasbindar Singh and explained the purpose of the visit. The facility is licensed to serve six (6) non ambulatory residents over the age of 60 and has an approved hospice waiver for four (4).

LPA OBSERVATIONS: The facility is a single-story dwelling located on a main street with three (3) resident bedrooms, two (2) staff bedrooms, two (2) bathrooms, kitchen, dining room, living room, front yard, backyard, and attached garage.

Front Yard: Was clean and well maintained. LPA Ramirez observed gate that leads to backyard to be wide open.

Kitchen: LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed knives and sharps located in kitchen cabinet, to be inaccessible to four (4) out of four (4) residents in care. LPA Ramirez observed several bottles of cleaning solutions and disinfectants located nearby kitchen hallway cabinet, to be accessible to four (4) out of four (4) residents in care. LPA Ramirez observed a sign posted on cabinet door indicating to “lock cupboards at all times”, a pad lock was observed but not secured. Kitchen sink water temperature was measured at 114.2 degrees F. Kitchen appliances were observed to be clean and in working order. Two cabinet doors located by sink were in disrepair. Cabinet drawer containing paper items was loose and not opening correctly to its original design. LPA could see exposed nails. Upper cabinet door containing resident plates, cups and other dishware, was missing doorknob.

Dining Room/Living room/: Dining room was observed to be clean and contained one table with plenty of seating. Living room was observed to have plenty of seating and lighting. Nearby thermostat was observed to read 78 degree F.

Linen Closet: Contained plenty linens, towels, and hygiene products.



SEE 809-C
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 11/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/26/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5


Document Has Been Signed on 11/26/2023 04:08 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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: 11/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)(1)
Maintenance and Operation
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. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, 6x6 gap was observed in bathroom#2 floor near shower, the licensee did not comply with the section cited above in 4out of 4 residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2023
Plan of Correction
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Licensee will repair flooring and send picture via email by 12/4/23. . Licensee will instruct residents,staff, and visitors to use another bathroom till repair is made. Licensee will certift via email plans to address gap in floor.
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, disinfectants and cleaning solutions were observed to be accessible in kitchen hallway cabinet and laundryroom, the licensee did not comply with the section cited above in 3 out of 4 persons with dementia, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2023
Plan of Correction
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Licensee will secure disinfectants and cleaning solutions and make them inaccessible to residents with dementia. Licensee will certify via email by 11/27/23 plan to address training. Licensee will provide re-training and send proof of training by 12/4/23.
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: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 11/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/26/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5


Document Has Been Signed on 11/26/2023 04:08 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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: 11/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
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:
Deficient Practice Statement
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Based on observation, 2 kitchen cabinet doors located by sink were in disrepair. Cabinet drawer containing paper items was loose and not opening correctly to it's original design. LPA could see exposed nails. Upper cabinet door containing resident plates, cups and other dishware, was missing door knob, the licensee did not comply with the section cited above in 4 out of 4 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/04/2023
Plan of Correction
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Licensee will repair and send photo proof via email.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 11/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/26/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 11/26/2023 04:08 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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: 11/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(j)
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, auditory devices on 3 doors in the facility were not observed to operable,the licensee did not comply with the section cited above in 4 out of 4 residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2023
Plan of Correction
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Licensee will certify via email plan to address re-training and licensee will send proof of re-training by 12/4/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 11/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/26/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: MOUNTAIN VIEW COTTAGES - IV
FACILITY NUMBER: 198204376
VISIT DATE: 11/26/2023
NARRATIVE
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Resident Rooms 1 - 3: LPA Ramirez inspected three (3) resident bedrooms and observed all bedrooms to contain required furnishings, lighting, and linens. Auditory device located on resident#2 exit door that leads to back yard, was observed to be in “Off” position. Administrator Singh placed device in “On” position after LPA Ramirez expressed concern.

Bathrooms: Water temperature in both resident bathrooms were within 105- 120 degrees F. Bathroom #2 located near laundry room was observed to have 6 x 6 gap in flooring. LPA touched flooring and wood felt soft and wet. LPA Ramirez observed wall near outside shower tile to be stain with brownish-yellow stains, dry wall was peeling and cracking on both sides.

Backyard: Was clean and well maintained. Plenty of shade and seating was observed. LPA Ramirez observed back yard gate to be wide open.

Emergency Drills: Last documented drill was conducted on 11/11/23 at 3 pm.

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide in hallways and smoke detectors were observed to be operable.

Personnel Records: Personnel records are maintained at facility. LPA Ramirez reviewed staff files for three (3) staff.

Resident Files: Four (4) resident files were reviewed.

Liability Insurance & Infection Control Plan: Facility has current liability insurance on file. LPA Ramirez observed updated infection control plan.



Laundry Room: LPA Ramirez observed laundry room door to be wide open and access to bleach and laundry soap were observed. LPA Ramirez observed two (2) back doors near laundry room, to have auditory devices switched in “OFF” position and doors were observed to be wide open.

Deficiencies are being cited and a copy of this report, 809-D and appeals rights was provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5