198204377-1-9-2026-28-AS-BPEA-DQ739X-20260109170348

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198204377
Report Date: 01/09/2026
Date Signed: 01/09/2026 05:04:25 PM

Document Has Been Signed on 01/09/2026 05:04 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	MOUNTAIN VIEW COTTAGES - I		FACILITY NUMBER:	198204377
ADMINISTRATOR/ DIRECTOR:	PRISCO CASTILLO		FACILITY TYPE:	740
ADDRESS:	1147 CLEGHORN DR.		TELEPHONE:	(909) 861-8508
CITY:	DIAMOND BAR	STATE: CA	ZIP CODE:	91765
CAPACITY: 6		CENSUS: 4	DATE:	01/09/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:40 PM
MET WITH:	Jasbindar SIngh - Administrator		TIME VISIT/ INSPECTION COMPLETED:	04:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required-1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by Jennifer Discipulo and Rafia Kaysha Dinda Oktiafaza, Caregivers and explained the purpose of the visit. At 1:30pm, Jasbindar Singh, Administrator arrived and assisted LPA. The facility is license to serve (6) non ambulatory residents age 60 and above. Facility may retain (6) hospice residents. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control:Infection control practices and Personal Protective Equipment (PPEs) were maintained. Staff are adhering to infection control requirements. The facility has an Infection Control Plan and reviews the infection control procedures in the facility annually. Operational Requirements: The Infection Control Plan has been added to the Plan. Liability Insurance policy in the amount of $1,000,000.00 each occurrence and $3,000,000.00 in the total annual aggregate is valid, expires on 03/09/2026. Facility does not handle residents' cash resources. Physical Plant & Environment Safety: This facility is a single story home consists of (5) resident bedrooms, (1) staff bedroom, (3) bathrooms, living room, family room, kitchen, dining room and backyard. There are (4) residents residing in the home. Resident bedrooms were toured. All bedrooms have sufficient storage space and lighting. Bathrooms have grab bars and non-skid mats. Knives, cleaning solutions, and disinfectants are locked and inaccessible to residents. There is a carbon monoxide detector located near the kitchen and smoke detectors are operable. LPA observed a fire extinguisher near the family room which was last serviced on 02/18/2025. Water temperature readings are within the required 105 - 120 degrees Fahrenheit. Indoor passageways were kept free of any obstruction and there are no pools or large bodies of water. Backyard was inspected and LPA observed boxes of miscellaneous items obstructing the passageways in the backyard and side yard. There is a sitting area with outdoor furniture but there is no umbrella or shade provided.***Refer to LIC 809C for the continuation of this report.***

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/09/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MOUNTAIN VIEW COTTAGES - I	FACILITY NUMBER: 198204377
	VISIT DATE: 01/09/2026

NARRATIVE

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Staffing: A total of (4) staff members including the night staff and Administrator provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility. Current Administrator's certificate is valid, expires on 04/11/2027.
Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed (4) staff files including the Administrator. Proof of staff training, health clearance, and vaccinations are current. Dementia care is part of training for direct care staff.
Resident Rights-Information: Resident rights are posted. Facility provides internet service and phone to the residents.
Planned Activities: The facility provides sufficient space to accommodate both indoor and outdoor activities. Food Service: There is sufficient food supplies of 2-day perishable and 7-day supplies of non-perishable items. The food is properly stored in the refrigerator. Pesticides and cleaning supplies are kept away from the food preparation areas. There is one (1) resident with restricted diet residing at this facility.
Incidental Medical Services: The medications are centrally stored and in their original containers. The facility uses the Medication Administration Record (MAR) log to document medications given.
Resident Records-Incident Reports: LPA reviewed (4) resident files. Residents files are maintained at the facility. Physician's Report (including TB and Ambulatory Status), Consent For Medical Treatment, Special Incident Reports, Client Personal Property and Clients Personal Rights observed.
Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan which is posted. Disaster drills are conducted quarterly, last drill was conducted on 12/01/2025.
Residents with SHN: Facility accepts and retains residents with dementia. Currently, there are (3) dementia residents and (1) hospice resident in the facility. Facility has sufficient space to permit residents with dementia to wander freely and safely. Administrator ensures that there is at least one night staff person awake and on duty for night supervision of residents with dementia. (1) of the residents using half bed rail did not have a physician's order on file.

Deficiencies cited on LIC 809D, Technical Violations and Technical Assistance issued. Exit interview, appeals rights and a copy this report was provided to Administrator, Jasbindar SIngh.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/09/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/09/2026 05:04 PM - It Cannot Be Edited

Created By: Bennette Pena On 01/09/2026 at 02:59 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MOUNTAIN VIEW COTTAGES - I	FACILITY NUMBER: 198204377
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/09/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87608(a)(5)(A)

Postural Supports

(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, record review, the licensee did not comply with the section cited above in that one of the residents using half bed rail did not have a physician's order on file which poses/posed a potential health, safety or personal rights risk to residents in care.
	POC Due Date: 01/23/2026
	Plan of Correction
1 2 3 4	Administrator to ensure that residents with bedrails have the required physician orders on file. Administrator will send a copy of the resident's physician's order for a half bedrail to CCL/LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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.

	Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:

	Bennette Pena
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/09/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2026

LIC809 (FAS) - (06/04)

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