198204377-3-9-2023-28-AS-FFIS-CPRVNS-20230309153536

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198204377
Report Date: 02/16/2018
Date Signed: 03/09/2023 03:37:23 PM

COMPREHENSIVE INSPECTION

Document Has Been Signed on 03/09/2023 03:37 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
, 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: 6	DATE:	02/16/2018
TYPE OF VISIT:	Annual/Required	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Administrator Jasbindar Singh		TIME COMPLETED:	04:00 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	LPA Fernando Fierros conducted an unannounced annual required visit for 2017 and met with Manager Jasbindar Singh. The purpose of the visit was discussed. During visit LPA Fierros spoke with Administrator Trupti Mody. Manager Jasbindar Singh states the facility has no weapons, ammunition's or bodies of water on premises. Manager Jasbindar Singh states the facility presently has three residents with dementia, no bedridden residents and no residents on Home Health or Hospice. Administrator Trupti Mody states the facility has video surveillance in the common area of the facility has been in use for around one year and is used for monitoring of staff, however, the licensee did not update the plan of operation with licensing in regards to the use an purpose of the Video Surveillance. Administrator states the facility will cease use of video surveillance and submit an updated Plan of Operation to licensing for review. The facility is a single story structure located in a residential area and contains the following: living room, dining room, family room, five resident rooms and one staff room, a kitchen, resident room #2 contains a bathroom with a washbasin, toilet and shower/tub, two common bathrooms with washbasin, toilet; one with a shower/tub and one with a walk-in shower, an outdoor shaded area for resident use in the backyard and a front yard. During visit LPA Fierros along with staff Victoria Montoya toured the physical plant and observed the following: required postings, operating within limits of license, auditory device operational, hallways and door ways clean and free of debris, adequate lighting and comfortable temperature throughout, sample food menu and activities observed, adequate 2 day perishable and 7 day non perishable food supply, see continuation page LIC 809C

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Fernando Fierros	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2018

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2018

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: 02/16/2018

NARRATIVE

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smoke alarms tested, carbon monoxide alarm tested and operational, sharps and toxins observed,, sufficient cups, plates and utensils, grab bars and anti skid mats in bathroom observed, sufficient linens and hygiene supplies, hot water temperature measured at 110*F in residents common bathroom, MARs reviewed, resident and staff files reviewed.

At 09:20 AM, LPA Fierros observed the residents food was locked in the kitchen food pantry. Staff Victoria Montoya states the food is locked at night to prevent residents from getting into the food. Manager Singh states the facility does not have a waiver to lock the food supply.

At 10AM, LPA Fierros observed toxins, a plastic container of bleach, powder laundry detergent in an unlocked cabinet in the laundry area and a can of paint and All Purpose Joint Compound in the side of the house in the backyard which is accessible to residents with dementia. Staff Victoria Singh was unable find the key to lock the cabinet and moved all items to an area inaccessible to residents with dementia.

At 10:30 AM, LPA Fierros observed resident #1 file did not contain written orders for Vitamin D-3 2000 IU and staff Victoria Montoya gave resident #1 the supplement for the period 02/01/18 through 02/15/18. Staff Montoya could not find a written order to give to LPA Fierros

At 10:30AM, LPA Fierros observed staff Victoria Montoya was giving resident #1 vitamin B-12 1000 mcg soft gel once a day for the period 02/01/18 through 02/15/18 and the written order was for B-12 Cyanocobalamin 2500 mcg SL Subl Tab - dissolve under tongue daily. Staff Victoria Montoya states residents family gave her the vitamin B-12 supplement with the dosage of 1000 mcg and in soft gel.

At 11:30AM LPA Fierros observed resident #3 medication Latanoprost 0.0005% eye drops were stored in an unlocked refrigerator and accessible to residents with dementia. Manager Singh states she would obtain a lock box for the medication. During visit, Staff Victoria moved resident #3 medication to an area inaccessible to residents with dementia.

see continuation page LIC 809C

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Fernando Fierros	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2018

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2018

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: 02/16/2018

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At 10:20 AM LPA Fierros observed common bathroom #3 did not have a grab bar near the toilet. Staff Victoria Montoya stated the wall was recently repaired and the grab bar has not been reattached.

At 10:20 AM, LPA Fierros observed the smoke alarm in staff room was non operational. Staff Victoria Montoya did not know why it was not working. Cleared during visit, Staff replace battery and smoke alarm is operational.

At 11:10 AM LPA Fierros was informed by Manager Singh and Staff Victoria Montoya that all residents #1-#6 are prepared and stored the day prior for morning, evening and bedtime and stored in a clear cup in a clear plastic box.

At 11:20 AM LPA Fierros observed the First Aid Kit did not contain a First Aid Manual from an approved agency. Manager Singh states she is unable to locate the First Aid Manual. .

At 09:40AM LPA Fierros observed the wall near bathroom #3 and the wall in bathroom #3 are not painted. The backyard contains debris on the walkway on the side of the house, several mattresses, boxes, a wheelchair, walker and hoyerlift.

Deficiency noted on todays visit were cited on the Licensing Report LIC 809 dated 02/16/18 for the Year 2016 per Title 22 Division 6 Chapter 8. Appeal Rights discussed and a copy given during visit. Exit interview conducted with Manager Singh.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Fernando Fierros	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2018

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2018

LIC809 (FAS) - (06/04)

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