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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603419
Report Date: 03/20/2024
Date Signed: 03/20/2024 11:31:17 AM

Document Has Been Signed on 03/20/2024 11:31 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: 4DATE:
03/20/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:08 AM
MET WITH:Felicitas Soralbo, Assistant AdministratorTIME COMPLETED:
11:40 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, Betty Espera. The assistant administrator, Felly Soralbo, arrived shortly to assist with the visit.

LPA conducted the remainder of the CARE tool domains during the visit today:
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. LPA reviewed 4 personnel files and they all have the required documentation. Staff have current CPR/first aid training and sufficient on-going training. Administrator (Paul Tabachnikov) has the HIV & TB certificate that was completed on 11/19/23.
Client Rights: Facility has an internet access device for clients to use.
Client Records-Incident Reports: Client files are maintained at the facility. LPA reviewed (4) client files and their files contain the required documentation such as the admission agreement, IPP, medical assessment with TB results, and safeguard of cash and inventory form.
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 4 clients and meds are being administered as prescribed by the physician.
Incidental Medical & Dental: There is currently no client with a restricted health condition.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Disaster drills are conducted quarterly.
Emergency Intervention: All staff have the CPI training and only use techniques taught by the CPI instructor.
There are no deficiencies issued today. An exit interview was held and a copy of this report was given to Ms. Soralbo.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2024
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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