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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603419
Report Date: 04/01/2022
Date Signed: 04/01/2022 01:03:44 PM

Document Has Been Signed on 04/01/2022 01:03 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:PT MOUNTAIN VIEW HOME INC.FACILITY NUMBER:
198603419
ADMINISTRATOR:TABACHNIKOV, PAULFACILITY TYPE:
735
ADDRESS:23546 SUNSET CROSSING RD.TELEPHONE:
(310) 221-1383
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY: 4CENSUS: 3DATE:
04/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Eufracia Espera-Williams, StaffTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. Upon arrival, LPA met with staff, Eufracia Espera-Williams, who contacted the Administrator. LPA spoke with the Administrator, Paul Tabachnikov over the phone during this visit. The facility is an Adult Residential Facility (ARF) to serve adults ages 18 to 59. The capacity is for four (4) ambulatory clients. Currently, there are three (3) clients in placement. The facility is vendorized through San Gabriel Pomona Regional center. LPA discussed with administrator and staff regarding the purpose of today's visit and the inspection.

During the visit, the infection control domain tool was used, a tour of the facility was conducted, food supply was reviewed, and medications were reviewed.



The facility is a single-story house located in a residential neighborhood. LPA toured the facilities physical plant, indoor and outdoor. Facility consists of four (4) client bedrooms, two (2) bathrooms, living room, dining room, kitchen, laundry area in the attached garage, and an indoor/outdoor activity area. Client rooms are furnished with appropriate furniture for clients’ comfort. Bathrooms are operational and furnished with grab bars and nonskid surfaces. Common areas are observed for the ability to safely serve the needs of the clients. A shaded area with chairs is provided in the back yard. The yard is free of debris/ hazard. and there are covered trash cans. Sufficient supply of perishable and nonperishable foods is observed. Smoke detectors and carbon monoxide detector are operable and in compliance. Fire extinguisher is fully charged. Hot water temperature measured at 110.5 degrees Fahrenheit which is within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies are observed. The last Fire/ Emergency Drill was conducted on 01/19/22. Medications are centrally stored, locked and the records are current. Hazardous items are locked in the garage and inaccessible to clients. Annual licensing fees are current. Administrator certificate is current and expiration date is 06/05/23.
( - continued in LIC 809 C-)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 04/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/01/2022
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: PT MOUNTAIN VIEW HOME INC.
FACILITY NUMBER: 198603419
VISIT DATE: 04/01/2022
NARRATIVE
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Deficiencies were observed per California Code of Regulations, Title 22.

An exit interview was conducted with staff. This report was discussed with staff, Eufracia Espera-Williams, who’s signature on this form confirm receipt of these documents. A copy of LIC 809s report and appeal rights were provided.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 04/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/01/2022 01:03 PM - It Cannot Be Edited


Created By: Bonnie Tao On 04/01/2022 at 12:10 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: PT MOUNTAIN VIEW HOME INC.
FACILITY NUMBER: 198603419

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Buildings and Grounds

The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation during physical plant inspection, LPA observed: an exit side gate’s turn knob/latch on left side of the facility is broken; screen door of the backyard sliding door has 2 holes; dishwasher is not securely installed in place; front burner at the left side of the electric stove top is not working. The licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/07/2022
Plan of Correction
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Licensee need to ensure that all exit gates are operable at all times. Administrator agrees to repair the exit side gate’s latch, screen door of the backyard sliding door, securely install the dishwasher, and repair the front burner of the stove top. Administrator will send the pictures of the corrected items to Licensing. The proof of correction to be submitted to Licensing by POC due date.
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:Bonnie Tao
LICENSING EVALUATOR SIGNATURE:
DATE: 04/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/01/2022


LIC809 (FAS) - (06/04)
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