198601496-4-4-2025-28-AS-BPEA-DFER7L-20250404124631

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601496
Report Date: 04/04/2025
Date Signed: 04/04/2025 12:46:44 PM

Document Has Been Signed on 04/04/2025 12:46 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:	MONTANA VISTA		FACILITY NUMBER:	198601496
ADMINISTRATOR/ DIRECTOR:	CAROLYN WEST		FACILITY TYPE:	735
ADDRESS:	355 WEST MONTANA STREET		TELEPHONE:	(626) 398-8519
CITY:	PASADENA	STATE: CA	ZIP CODE:	91103
CAPACITY: 6		CENSUS: 6	DATE:	04/04/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:09 AM
MET WITH:	Jana West - Co-Administrator		TIME VISIT/ INSPECTION COMPLETED:	01:00 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	Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required-1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by Mathilde Tallayamande, DSP I & II and explained the purpose of today's visit. At 10:40am, Jana West, Co-Administrator arrived and assisted LPA with the inspection. The facility is licensed to serve (6) developmentally disabled adults ages 18-59 years, ambulatory only. Services provided by Frank D. Lanterman Regional Center, facility is level 4-G. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were maintained. Staff are adhering to infection control requirements. The facility has submitted a COVID-19 Mitigation Plan and the Infection Control Plan. Physical Plant & Environment Safety: This facility is a single story home consists of kitchen, dining room, living room with covered fireplace, (3) client bedrooms, (2) bathrooms, laundry area, detached garage, side yard and backyard with covered patio area. There are (6) clients living in the home, (2) of whom are in a temporary situation due to the Eaton fire and receive services from San Gabriel Pomona Regional Center. Client bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, chair and sufficient closet space. Smoke alarms and carbon monoxide were tested and operable. Laundry area is next to the kitchen area. Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients. There are no firearms or weapons stored at the facility. Fireplace is covered and inaccessible to clients. At 10:20am, hot water supply readings measured at 102.7 deg F in bathroom #1 and 100.9 deg F in bathroom #2, 2nd reading at 11:36am measured at 107.6 deg F in bathroom #1 and 108.2 deg F in bathroom #2. Water temperature readings measured were within the required 105 - 120 degrees Fahrenheit. Exit doors are free of any obstruction and there are no pools or large bodies of water. Backyard was inspected with a shaded area. Operational Requirements: A current Plan of Operation was reviewed. A fire clearance is in place. Surety bond is valid in the amount of $5000 and expires on 11/14/2026. Last Fire Drill was conducted on 01/28/2025 and earthquake drill on 02/10/2025. One (1) fire extinguisher mounted on the kitchen wall was last serviced on 02/24/2025. ***Refer to LIC 809C for the continuation of this report.***

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: MONTANA VISTA	FACILITY NUMBER: 198601496
	VISIT DATE: 04/04/2025

NARRATIVE

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Staffing: A total of eight (8) staff members including the Co-administrator provide care and supervision to the clients. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility. Co-administrator's certificate is valid and expires on 04/16/2026.
Personnel Records-Training: Staff files are not maintained at the facility. Co-administrator had to leave and get all the staff files from an off-site office location. LPA reviewed (3) staff files including the Co-administrator. Proof of staff training, health clearance, and vaccinations are current.
Client Rights-Information: Client personal rights are posted. Facility provides internet service and phone to the clients. However, the phone number for the facility that is on record is presently out of service. Co-administrator has reached out to the phone company to resolve the issue.
Food Service: There is sufficient food supplies of 2-day perishable and 7-day supplies of non-perishable items. The food is properly stored in the refrigerator. There are no clients with special diets residing at this facility. Pesticides and cleaning supplies are kept away from the food preparation areas.
Client Records-Incident Reports: LPA reviewed (4) client files. Client files are maintained at the facility. Admission Agreement, Physician's Report (including TB and Ambulatory Status), IPP, Consent For Medical Treatment, Special Incident Reports, Client Personal Property and Clients Personal Rights observed.
Health Related Services: The medications are centrally stored and in their original containers. LPA reviewed medication for (6) clients. The facility uses Medication Administration Record (MAR) to document medications given. Medications are administered as prescribed by the Physician.
Incidental Medical Services: Per Co-administrator, there are no clients at this home with incidental medical services nor have a restricted health condition.
Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan.
Emergency Intervention: Not-Applicable.

Deficiency cited and Technical assistance issued. Exit interview and a copy of this report was provided to Jana West, Co-administrator.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/04/2025 12:46 PM - It Cannot Be Edited

Created By: Bennette Pena On 04/04/2025 at 12:31 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: 04/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80066(e)

Personnel Records

(e) All personnel records shall be maintained at the facility site. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, record review, the licensee did not comply with the section cited above in that the staff/co-administrator had to leave and get all the staff files and other facility records from an off-site office location which poses/posed a potential health, safety or personal rights risk to clients in care.
	POC Due Date: 04/10/2025
	Plan of Correction
1 2 3 4	Co administrator agreed to duplicate copies and maintain facility records and staff files in the facility. Co-administrator to send a written statement to LPA/CCL by POC due date.

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.

	David Sicairos
NAME OF LICENSING PROGRAM MANAGER:

	Bennette Pena
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2025

LIC809 (FAS) - (06/04)

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