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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198204377
Report Date: 12/12/2022
Date Signed: 12/12/2022 11:42:37 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
12/05/2022 and conducted by Evaluator Luis Mora
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20221205092329
FACILITY NAME:MOUNTAIN VIEW COTTAGES - IFACILITY NUMBER:
198204377
ADMINISTRATOR:PRISCO CASTILLOFACILITY TYPE:
740
ADDRESS:1147 CLEGHORN DR.TELEPHONE:
(909) 861-8508
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY:6CENSUS: 4DATE:
12/12/2022
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Jasbindar Singh - AdministratorTIME COMPLETED:
11:56 AM
ALLEGATION(S):
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Facility has pests.
Facility is not maintained in a clean and sanitary condition.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced initial complaint visit to determine the validity of the above-mentioned allegations. LPA met with Jasbindar Singh (Administrator) and explained the reason for the visit.

The investigation consisted of the following: LPA Mora obtained copies of the resident and staff rosters, interviewed Administrator, Staff 1 - Staff 2 (S1 – S2), Resident 1 - Resdient 4 (R1 – R4) and conducted a tour of the facility.

The investigation revealed the following: regarding the allegation "facility has pests”, it is alleged that cockroaches were observed crawling in the facility's kitchen. Interviews with Administrator and staff revealed that they are aware of the cockroaches and have bought Hot Shot Roach Spray and AdvionAnt gel to kill the cockroaches. Administrator also stated that the last pest control service was done in October 2022 because the person that provides the services has been out of the country. (CONTINUED TO LIC 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis MoraTELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2022
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 3
Control Number 28-AS-20221205092329
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 - I
FACILITY NUMBER: 198204377
VISIT DATE: 12/12/2022
NARRATIVE
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Residents interviewed could not corroborate with the allegation. During the tour, the LPA observed multiple cockroaches crawling in the kitchen's cabinets.

Regarding the allegation "facility is not maintained in a clean and sanitary condition”, it is alleged that there is a layer of unknown residue on the top of the stove and a dead insect was observed attached to a web. Interview with Administrator revealed that a new stove was bought and will be delivered on 12/29/2022 because they are unable to remove the grease/oil residue from the stove. Best Buy receipt was observed by the LPA. Administrator also stated that the kitchen walls and cabinets will be cleaned and the walls will be painted. Residents interviewed could not corroborate with the allegation. During the tour, the LPA observed that the stove had a layer of oil/grease on the top part of it, the kitchen cabinets, walls and ceiling were stained with grease, roach droppings were observed inside the corners of the cabinets, and there was a dead insect attached to a web under the kitchen wall cabinets.

Based on LPA's interviews and observations, the preponderance of evidence standard has been met, therefore the allegations are found SUBSTANTIATED. California Code of Regulations Title 22, Division 6, Chapter 8 are being cited on the attached LIC 9099D.

Exit interview held and a copy of the report and appeal rights was provided.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis MoraTELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20221205092329
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 - I
FACILITY NUMBER: 198204377
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/26/2022
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation (a) 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 evidence by:
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Administrator is to ensure facility is maintain free of cockroaches at all times, will contact pest control services and create a plan that will eliminate the cockroaches in the kitchen and submit the new plan to the CCLD by 12/26/2022.
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Based on observation the licensee did not ensure the kitchen is free of cockroaches which poses a potential risk to the health, safety, or personal rights of the persons in care.
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Type B
12/26/2022
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation (a) 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 evidence by:
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Administrator is to ensure that the facility is maintain clean, sanitary and in good repair at all times, will replace the stove and clean kitchen's walls and cabinets. Pictures to CCLD will be submitted by 12/26/22

*The administrator showed the LPA a receipt for a new stove & will be delivered on 12/29/22*
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Based on observation the licensee did not ensure that the kitchen's walls, cabinets and stove are clean which poses a potential risk to the health, safety, or personal rights of the 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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis MoraTELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3