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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601496
Report Date: 04/07/2023
Date Signed: 04/18/2023 08:11:30 AM

Document Has Been Signed on 04/18/2023 08:11 AM - 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:MONTANA VISTAFACILITY NUMBER:
198601496
ADMINISTRATOR:CAROLYN WESTFACILITY TYPE:
735
ADDRESS:355 WEST MONTANA STREETTELEPHONE:
(626) 398-8519
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY: 6CENSUS: 4DATE:
04/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Facility Supervisor- Jana WestTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ashley Calderon made and unannounced Annual inspection focused on domains within the Compliance and Regulatory Enforcement (Care) Tools. Upon visit LPA met with DSP worker Willie Rhodes and later met with Facility Supervisor Jana West to discuss the purpose of the visit.

LPA Calderon started the Care Tools with DSP Willie and shortly after Jana assisted with domains.
LPA conducted a tour of the facility along side with Willie and DSP Worker Quiana Robinson. Facility is a one story family home with three (3) bedrooms, two (2) bathrooms, living room, kitchen, dining area, laundry room, backyard and an detached garage inaccessible to clients used as storage.

The following was conducted and inspected:
  • Outdoor and indoor passageways are free of obstruction.
  • Bathrooms were clean and operational with grab bars and non-ski mat, hot water measured within Title 22 regulation.
  • Smoke detectors were tested. The last fire drill was conducted on 11/09/2022. Done every 6 months.
  • Required postings observed.
  • The fire extinguisher is located in the kitchen.
  • Carbon Monoxide detector was located in the hallway, was tested and operable.
  • Sufficient supply of extra linen, towels and personal hygiene supplies. Linens supplies are stored inside the cabinets. PPE observed.
  • Comfortable temperature for clients was maintained.
  • Washer/Dryer appliances observed.
  • Front and back yard is in good condition, shaded area is provided.
(Continuation on 809-C...)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 04/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/07/2023
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: MONTANA VISTA
FACILITY NUMBER: 198601496
VISIT DATE: 04/07/2023
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KITCHEN:
  • Freezers/refrigerators appear sanitary and temperature maintained.
  • Sufficient non-perishable and perishable food items for clients in care, canned goods observed.
  • Toxins and sharps locked and inaccessible to clients.

BEDROOMS:
  • Bedrooms #1-#3 had required furnishing.
  • Beds have the required linen/supplies which include, pillowcase, mattress padding, fitted sheet, blanket and bedspreads.

MEDICATION:
  • Medications are stored, locked and inaccessible to clients, located in cabinet in the hallway.
  • Medication and First Aid Kit reviewed.
  • LPA reviewed (3) client medication, (1) client does not take medications and LPA discovered Client #3's medication Amlodipine Bes 5 MG and Levothyroxine Na, was not given according to the physician's directions and missed providing client medication for April 6,2023.

RECORD REVIEW:
LPA reviewed Staff and Client files. As a part of the inspection reviewed (4) resident records, (4) staff files. Currently the facility has (4) clients which (2) are ambulatory and (2) is non-ambulatory.
  • Facility Administrator Certificate for Carolyn West expires on 8/09/24 / Administrator Certificate for Jana West expires on 4/16/2024.
  • Staff (files reviewed) have current First Aid/CPR Certificates.
  • Staff (files reviewed) have Criminal Clearances on file.

Care Tool was completed and based on Title 22 Regulations Deficiencies will be documented on LIC 809D and Civil Penalties were issued.

An exit interview was conducted with Facility Supervisor Jana West and a copy of today's reports / appeal rights were provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/18/2023 08:11 AM - It Cannot Be Edited


Created By: Ashley Calderon On 04/07/2023 at 04:00 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MONTANA VISTA
FACILITY NUMBER: 198601496

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(5)(B)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the Staff / Licensee/ Administrator did not comply with the section cited above. One client in care, medication was not provided to client based on physician's directions which poses an immediate health, safety or personal rights risk to person(s) in care.
POC Due Date: 04/08/2023
Plan of Correction
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Facility Supervisor will immediately provide Client with appropriate medication needed once Facility Supervisor contacted client's Pharmacist via telephone with LPA Calderon present and verbally gave instructions for missed medication. Facility will provide LPA document regarding a in-service training with staff who administer medication, will review Title 22 Regulation on Health Related Services, review how to follow medication labels, and how to review/ organize Medication Log.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Fernando Fierros
LICENSING EVALUATOR NAME:Ashley Calderon
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2023


LIC809 (FAS) - (06/04)
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