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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603419
Report Date: 03/13/2023
Date Signed: 03/13/2023 11:45:10 AM

Document Has Been Signed on 03/13/2023 11:45 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
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:
03/13/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Virginia Hernandez, staffTIME COMPLETED:
11:50 AM
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Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit to continue the annual inspection. LPA arrived and met with Staff, Virginia Hernandez, who allowed entry. Administrator, Paul TAbachnikov arrived right after to assist with the visit.

LPA conducted the following domains during the visit today:
Operational Requirements: The facility is licensed for (4) ambulatory adults ages 18 - 59. There are currently 3 clients residing at the home and receive services through the San Gabriel/Pomona Regional Center.
Staffing: There is sufficient staffing at the facility, with (2) staff in the morning and afternoon shifts and (1) in the overnight shift. Staff are fingerprint cleared and associated to the facility.
Personnel Records-Training: Staff files are maintained at the facility. Administrator (Paul Tabachnikov) certificate expires on 06/05/23. Staff have current CPR/first aid training and sufficient on-going training that meets the annual requirement. LPA reviewed (4) personnel files and they all have required documentation.
Resident Records-Incident Reports: Resident files are maintained at the facility. LPA reviewed all (3) client files and they have the required documentation including current Individual Program Plan. There are no clients with a restricted health condition and are all ambulatory.
Food Service: There are sufficient food supplies of 2-day perishable and a week of non-perishable items. Freezers are maintained at a temperature of 0 degree F and the refrigerators at a maximum of 45 degrees F. Both are kept clean and food are properly stored.
Health-Related Services: The medications are centrally stored and locked. The facility uses the Medication Administration Record (MAR) log to document medications given. LPA reviewed medications for all 3 clients and they are being administered as prescribed by the physician.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 03/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2023
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PT MOUNTAIN VIEW HOME INC.
FACILITY NUMBER: 198603419
VISIT DATE: 03/13/2023
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Incidental Medical & Dental: There are no clients who require health services or have a health condition that need to be monitored more carefully.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Staff are provided training on the emergency procedures and know where the utility shutoff valves are located. The client roster is posted and the clients' face sheet have been updated.
Emergency Intervention: Staff have CPI training and are up-to-date. Their CPR/first aid certificates have not expired. The staff do not need to use manual restraint on the clients at this home and utilize de-escalation techniques.

There are no deficiencies issued today. LPA provided a technical assistance in reference to the emergency drill that is required at least quarterly for each shift, with different scenarios.

An exit interview was held. A copy of this report and technical advisory note was given to administrator Tabachnikov.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2023
LIC809 (FAS) - (06/04)
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