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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603419
Report Date: 03/09/2023
Date Signed: 03/09/2023 04:23:28 PM

Document Has Been Signed on 03/09/2023 04:23 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: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:
03/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Virginia Hernandez, staffTIME COMPLETED:
04:25 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA arrived unannounced and met with Staff, Virginia Hernandez. The purpose of the visit was explained. The facility is licensed for (4) ambulatory clients, ages 18 - 59.

LPA toured the facility and conducted the following domains:

Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting at least once during each shift and more often for high touched surfaces. Facility has sufficient PPE supplies and still screening for COVID-19 symptoms. LPA requested for the administrator to submit the Infection Control Plan.

Physical Plant & Environment Safety: The facility does not have any pool or bodies of water on the premises. There are 4 client bedrooms, 2 bathrooms, living room, dining room, kitchen, and attached garage. Each client bedroom has the required furniture and bedding. Extra hygiene supplies were observed. Facility has an operable smoke detector in each room and 2 carbon monoxide detectors. Knives, cleaning solutions, and disinfectants are locked, making them inaccessible to clients. There are no firearms or weapons stored at the facility. The hot water temperature in the bathrooms were measured between the required range of 105-120 degrees F.

LPA will return to complete the remainder of the domains on a later date. An exit interview was conducted and a copy of this report was given to staff Virginia.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 03/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/09/2023
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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