198204377-12-12-2023-28-AS-CDCN-CYG27G-20231212160844

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198204377
Report Date: 12/12/2023
Date Signed: 12/12/2023 04:08:59 PM

Document Has Been Signed on 12/12/2023 04:08 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: 2	DATE:	12/12/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:40 PM
MET WITH:	Jacqueline Runtukahu, Staff		TIME COMPLETED:	04:15 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) Cynthia Chan conducted the required annual inspection on 12/12/23. LPA arrived unannounced and met with staff, Jacqueline Runtukahu. The reason for the visit was explained. Administrator, Jas Singh, arrived shortly after to assist with the visit. LPA utilized the Compliance and Regulatory Enforcement (CARE) Tools. The following were observed: Infection Control: The facility has submitted an Infection Control Plan. Staff are continuing to clean and disinfect the home. They are using appropriate hand hygiene and wearing gloves while assisting residents. Operational Requirements: The facility has a dementia care plan to accept or retain residents with dementia. There are no residents utilizing oxygen at this time. Facility has the required amount of liability insurance coverage. Physical Plant & Environment Safety: The facility consists of 5 resident rooms, 1 Staff room, living room, dining room, family room, kitchen, 3 bathrooms, and attached garage. The hot water temperature was measured between the required range of 105-120 degrees F. There are no swimming pool or bodies of water on the premises. The fireplace is adequately screened. There are smoke detectors located in each bedroom. Food Service: There are sufficient food supplies of 2-day perishable and a week of non-perishable items. The food are properly stored in the refrigerator. Staffing: The facility has sufficient staffing to meet the needs of the residents. All staff members have current CPR & First Aid certificates. Personnel Records-Training: LPA reviewed 3 Staff files. The administrator's (Jasbindar Singh) certificate expires on 4/11/25. Staff have fingerprint clearance and associated to the facility. Staff files have the required documents such as personnel record, health screening with TB results, employee rights form, and in-service training. Staff also have appropriate dementia care training.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

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: 12/12/2023

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
26
27
28
29
30
31
32

Resident Records-Incident Reports: LPA reviewed 2 resident files. The files contain the admission agreement, medical assessment with TB results, consent forms, property valuable form, preappraisal form, and personal rights form.
Resident Rights-Information: Information for appropriate reporting agencies are posted at the facility. Residents' rights are respected and implemented by staff.
Planned Activities: Facility has sufficient space to provide indoor and outdoor activities to accommodate residents.
Incidental Medical and Dental: LPA reviewed medications for both residents and are being administered as prescribed.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Emergency procedures are indicated on the form. Disaster drills are conducted and documented quarterly.
Residents with Special Health Needs: Facility accepts and retains residents with dementia. Staff are ensuring that incontinence residents are changed often and the facility remains free of odor from incontinence. There are no residents currently with prohibited or restricted health conditions.

No deficiencies were issued today. An exit interview was held and a copy of this report was given to the administrator.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2