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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530320
Report Date: 07/06/2026
Date Signed: 07/06/2026 04:08:57 PM

Document Has Been Signed on 07/06/2026 04:08 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:MOUNTAIN VIEW SENIOR LIVINGFACILITY NUMBER:
335530320
ADMINISTRATOR/
DIRECTOR:		BALANQUIT,IEZLFACILITY TYPE:
740
ADDRESS:20400 GRAND AVETELEPHONE:
(858) 284-9114
CITY:WILDOMARSTATE: CAZIP CODE:
92595
CAPACITY: 6CENSUS: 3DATE:
07/06/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Lindsay Jacobo, Caregiver/DesigneeTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Andrew Martinez made an unannounced visit to the facility to conduct a required comprehensive annual inspection. LPA Martinez met with Caregiver Richard Padilla and was granted entry into the facility. LPA met with Caregiver/Designee Lindsay Jacobo and explained the purpose of today's visit. At time of visit, the facility's census was three (3), with (2) staff and (3) residents present.

The facility is Residential Care Facility for the Elderly (RCFE) operating in the capacity approved by the Community Care Licensing Division (CCLD). The facility is licensed with a fire clearance for a capacity of six (6) non-ambulatory residents; the facility currently holds a hospice waiver for (2). LPA Martinez was accompanied by Caregiver/Designee Lindsay Jacobo to conduct a general overall inspection, which included, but was not limited to the following:

Physical Plant: The facility is a single-story, three (3) bedroom, two (2) bathroom home with a kitchen, dining area, living room, open porches, and a detached two (2) car garage. LPA Martinez observed no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 78 degrees Fahrenheit. LPA Martinez inspected resident bedrooms; they are equipped with required amenities including furniture such as mattresses, lamps, nightstands, storage space, and sufficient lighting. LPA Martinez observed (1) window screen in Resident #1 (R1) room is missing. Deficiency B will be issued. LPA Martinez observed that bathrooms were clean, equipped with working toilets, wash basins, and showers with grab bars and non-skid mats. LPA Martinez observed an adequate supply of extra linens, towels, toilet paper and soaps. Hot water temperature in resident’s bathroom was measured at 109.3 and 111.3 degrees F; kitchen hot water tap measured at 107.3 degrees F.
*** Continued on LIC 809C ***
NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Andrew Martinez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/06/2026
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.

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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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MOUNTAIN VIEW SENIOR LIVING
FACILITY NUMBER: 335530320
VISIT DATE: 07/06/2026
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LPA observed a sufficient supply of hygiene items stored for residents use, night lights maintained throughout facility, and sufficient furniture for residents in care. The facility is equipped with operating combined smoke detectors and carbon monoxide alarms, as well as stand-alone carbon monoxide detectors. LPA Martinez observed auditory devices that monitor exits and alert staff. Posters such as personal rights, the CCLD complaint poster, Ombudsman Poster and the Emergency Disaster plan were posted in a common area. There was a designated storage space for resident and staff files, and locked cabinets located in the kitchen that centrally store the resident's medication. The facility has a fully stocked first aid kit, however, does not have a current, regulation approved first aid manual. A technical violation deficiency will be issued.

Food Service: Seven (7) days non-perishable and two (2) days perishable food supply observed at the facility. Refrigerator and freezers were observed to be clean and in good working condition.

Care & Supervision: The facility's administrator was not present, however, caregiver Lindsay Jacobo, with designation of facility responsibility, was present throughout visit. LPA Martinez observed enough staff present and scheduled per LIC 500 to provide 24/7 care and supervision to residents in care as required for a facility with dementia residents.

Record Review: LPA Martinez observed the facility's Emergency and Disaster Plans, and Infection Control Plans. LPA reviewed three (3) resident files for admission agreements, updated physician reports, pre-placement appraisals, centrally stored medication list, and needs and services plans. LPA Martinez observed the required Pre-Admission Appraisals for (3) of (3) residents were not stored in resident's files and could not be provided to LPA during visit. Deficiency B will be issued. LPA Martinez audited (3) of (3) resident's medication against their Medication Administration Records (MARS) that revealed Resident #1 (R1) has (1) medication in which the bottle label does not reflect the exact dosage accurately per updated physician's order, and (3) of Resident #2's (R2) medications were not given or documented correctly per R2's physician order. Deficiencies A & B will be issued. LPA reviewed two (2) staff files for criminal record clearance, medical assessment/health screening reports, tuberculosis (TB) test results, required training, and First Aid/CPR certification. Staff files reviewed were observed to be complete.

Based on today's observations and records reviewed, (1) type A, (3) type B, (1) TV deficiencies were cited per Title 22, Division 6, Chapter 1 of the California Code of Regulations. An exit interview was conducted where this Facility Evaluation Report (LIC 809, LIC 809C), Deficiencies & Plans of Corrections (LIC 809D), LIC 9102 and Appeal Rights were discussed and provided to Caregiver/Designee Linsday Jacobo.

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Andrew Martinez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/06/2026 04:08 PM - It Cannot Be Edited


Created By: Andrew Martinez On 07/06/2026 at 03:30 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MOUNTAIN VIEW SENIOR LIVING
FACILITY NUMBER: 335530320

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/06/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that three (3) of Resident #2 (R2) medications were given per R2's physician orders which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/07/2026
Plan of Correction
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LIcensee stated to utilize Centrally Stored Medication Record and Medication Administration Records (MARS) accurately to ensure staff at the facility are giving R2's medications per R2's physician order. Caregiver submitted proof to LPA Martinez during the visit. Plan of Correction (POC) cleared.
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.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Andrew Martinez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/06/2026 04:08 PM - It Cannot Be Edited


Created By: Andrew Martinez On 07/06/2026 at 03:30 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MOUNTAIN VIEW SENIOR LIVING
FACILITY NUMBER: 335530320

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/06/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above by not ensuring Resident #1 (R1) bedroom window is equipped with a screen that is clean and in good repair which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/17/2026
Plan of Correction
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Licensee to install a window screen in Resident #1 (R1) bedroom window and submit a statement of understanding for the cited regulation along with photographic proof of screen installation to Licensing via email by end of business on POC due date.
Type B
Section Cited
CCR
87465(h)(4)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above by ensuring (1) of Resident #2 (R2) prescription medications were refilled with medication bottles accurately labled per current physician's orders which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/17/2026
Plan of Correction
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Licensee to obtain and verify accruate labeling according to physician's prescription orders on all medciation refills for R2. Licensee to review regulation in full and sumbit a signed statement of understanding to Licensing via email by end of business on POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Andrew Martinez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2026


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 07/06/2026 04:08 PM - It Cannot Be Edited


Created By: Andrew Martinez On 07/06/2026 at 03:30 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MOUNTAIN VIEW SENIOR LIVING
FACILITY NUMBER: 335530320

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/06/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not completing the required pre-admission appraisals for (3) of (3) residents which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/17/2026
Plan of Correction
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LIcensee to review regulation in full and submit a signed statement of understanding to Licensing via email by end of business on day on POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Andrew Martinez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2026


LIC809 (FAS) - (06/04)
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