198204377-12-1-2021-28-AS-LMOA-C9AU9R-20211201142331

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198204377
Report Date: 12/01/2021
Date Signed: 12/01/2021 02:23:41 PM

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 - I		FACILITY NUMBER:	198204377
ADMINISTRATOR:	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:	12/01/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Administrator Jasbindar Singh		TIME COMPLETED:	02:30 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) Luis Mora conducted an unannounced annual visit using the Infection Control Evaluation Tool. LPA met with Caregiver Jennifer Discipulo and explained the reason for the visit. The Administrator Jasbindar Singh arrived shortly after. The physical plant was toured, resident files and medications records were reviewed, staff files were reviewed and food supply was inspected. Facility is licensed to serve 6 non-ambulatory residents age 60 and above and may retain one hospice resident. LPA and Caregiver Jennifer Discipulo toured the facility which included the following: family room, living room, kitchen, dining area, 3 bathrooms, 5 resident rooms, 1 staff room, and backyard. Passageways and exits are free of obstruction. The water temperature was tested in the 3 resident bathrooms and measured between 105.1 - 110 degrees F which is within the required 105 - 120 degrees F. The resident bathrooms are clean and have the required grab bars in the shower and near the toilet for non-ambulatory residents. Showers also have non-skid materials. Resident bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Resident beds have the required linen and the linen is in good condition. Bedrooms also have sufficient closet space. There is a cabinet in the hallway with extra clean linen. Smoke detectors were tested and observed throughout the facility and in each resident room. Carbon monoxide detectors were tested and observed in the hallway and family room area. Auditory devices were seen on exit doors which are required for dementia residents and were operating a the time of visit. LPA observed 1 fire extinguisher in the kitchen which was fully charged. Kitchen appliances are clean and were operating at the time of the visit. Sharps are locked under the kitchen sink and are inaccessible to residents. Cleaning supplies, toxins and hygiene products are locked in a closet in the hallway and are inaccessible to residents. The First Aid kit which is located in a locked closet in the hallway was inspected and is fully stocked with current manual. Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing. Sufficient supply of 2 days perishable & 7 days non-perishable foods were observed in the kitchen. (CONTINUED TO LIC809C)

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-4934
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021

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 - I	FACILITY NUMBER: 198204377
	VISIT DATE: 12/01/2021

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Medications, resident files, and staff files are kept in a locked closet in the hallway. The backyard is clean and there is a shaded seating area for the residents. No bodies of water were observed at the facility.

LPA reviewed 5 staff files and observed the following: 5 out of 5 staff have criminal record clearances and are associated to the facility, 5 out of 5 staff have proof of in-service training, 5 out of 5 staff files have health screenings with TB information, and 5 out of 5 staff have current first aid/CPR certificates.

LPA reviewed 4 residents files and medications, and observed the following: 4 out of 4 resident have admission agreements on file, 4 out of 4 have their needs and services plans up to date, and 4 out of 4 have physician's reports on file and TB information, and 4 out of 4 have their medications documented properly and given as prescribed.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there was no deficiencies observed during the visit. Exit interview held and a copy of the report was provided.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-4934
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021

LIC809 (FAS) - (06/04)

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