198204377-12-1-2022-28-AS-KRAZ-CLQ3DZ-20221201171023

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198204377
Report Date: 12/01/2022
Date Signed: 12/01/2022 05:11:35 PM

Document Has Been Signed on 12/01/2022 05:11 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 - 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:	12/01/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:56 PM
MET WITH:	Administratoe Jasbinder Singh		TIME COMPLETED:	05:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced annual visit using the Infection Control Evaluation Tool. LPA met with Administrator Jasbindar Singh and explained the reason for the visit. The physical plant was toured, medications records were reviewed, and food supply was inspected. Facility is licensed to serve six (6) non-ambulatory residents age 60 and above and may retain six (6) hospice residents. There are currently four (4) residents residing in the home; two (2) are ambulatory and two (2) are non ambulatory. The facility is single story home located on a residential street. The facility has an open front yard and enclosed backyard with an attached patio cover.

LPA and Administrator Singh toured physical plant. LPA observed passageways and exits are free of obstruction. During the tour, LPA observed a living room area, kitchen, dining room area, four (4) resident bedrooms, one (1) staff bedroom, and three (3) bathrooms. The water temperature was tested in all resident bathrooms and measured between 108.5 - 112 degrees F which is within the required 105 - 120 degrees F. Bathrooms 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. LPA observed bedroom#1 to have missing/broken blinds. Bedroom#2 is currently empty. 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 at the time of visit. LPA observed 1 fire extinguisher in the kitchen which was fully charged and last inspected in January of 2022. LPA observed the top of the stove, wall located directly behind stove, cabinet above the stove and ceiling located directly under the stove to have caked on grease and food splatter. LPA observed missing/broken blinds in kitchen above sink. 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 was observed in the kitchen. LPA observed missing/broken blinds in living room.

CONT 809C

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022

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
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: 12/01/2022

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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 four (4) staff files and observed the following: out of four (4) staff have criminal record clearances and are associated to the facility, four (4) out of four (4) staff files have health screenings with TB information, and four (4) out of four (4) staff have current first aid/CPR certificates.

LPA reviewed 4 residents medications and observed the following: 4 out of 4 medications documented properly and given as prescribed.

Deficiencies cited on the 809 D.

Exit interview conducted and appeals rights provided .

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/01/2022 05:11 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 - I	FACILITY NUMBER: 198204377
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/01/2022

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
1 2 3 4	Based on observation, missing/broken blinds in bedroom #1 and living room area, caked on grease and food splatter on stove backsplash and surrounding walls; the licensee did not comply with the section cited above in; which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/15/2022
	Plan of Correction
1 2 3 4	Administrator/Licensee will provide photo proof of replaced blinds, cleaned and sanitized area above stove and surrounding stove walls.

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.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022

LIC809 (FAS) - (06/04)

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