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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600002
Report Date: 07/23/2024
Date Signed: 07/23/2024 03:22:42 PM

Document Has Been Signed on 07/23/2024 03:22 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:MOUNTAIN VIEW CAREFACILITY NUMBER:
198600002
ADMINISTRATOR/
DIRECTOR:
CAROLINE TANFACILITY TYPE:
735
ADDRESS:2622 MOUNTAIN VIEW ROADTELEPHONE:
(626) 448-1682
CITY:EL MONTESTATE: CAZIP CODE:
91732
CAPACITY: 83CENSUS: 76DATE:
07/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Staff Aristotle Tan TIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit and was greeted by Staff Aristotle Tan and explained the reason for the visit.
The purpose of the visit is to complete the required inspection.
LPA Trueman toured the facility along with Staff Aristotle Tan today 07/23/2024 at 11:15 AM and the following was observed
Facility contains 42 Bedrooms, dining room, kitchen, TV room, and activity room.
LPA inspected Rooms which included 1st Floor #5, 6, 9, 10, 11,12, 17, 25 and 26 and on the 2nd Floor 35, 36 ,37, 38, 43, and 44.
Hot water temperature measured between 105 F. and 120 F. meeting Title 22 Regulations.
Required Annual Inspection included Infection Control Practices, Operational Requirements, Physical Plant/ Environmental Safety, Staffing, Personnel Records/ Staff Training, Resident Records/ Incident Reports, Resident Rights/ Information, Food Service, Health Related Services, Incidental Medical Services, and Disaster Preparedness.
LPA observed sufficient supply of 2 day perishables and 7 day non perishables.
All staff were cleared and associated.
Visitation signage was posted along with signage for hand washing and proper sanitizing.
Staff responsible for providing care and supervision received training in First Aid.
Licensee maintained an individual admission agreement for each client.
Fire Clearance has been maintained.
Each client has personal rights free from corporal or unusual punishment, infliction of pain, humiliation, ridicule, coercion, threats, mental abuse, or other actions of a punitive nature.
Program site was clean, safe, sanitary, and in good repair at all times for the safety and well being of clients, employees and visitors.
Medication was reviewed for 8 Client's. 8 Client Files and 6 Staff Files were reviewed.
Interviews were conducted with 5 Client's and 2 Staff.

No deficiencies. Exit interview conducted.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE: DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2024
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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