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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360909015
Report Date: 09/10/2020
Date Signed: 09/10/2020 05:33:34 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:MONTCLAIR GUEST HOME IFACILITY NUMBER:
360909015
ADMINISTRATOR:DINA MOPERAFACILITY TYPE:
740
ADDRESS:4515 ORCHARD STREETTELEPHONE:
(909) 624-5575
CITY:MONTCLAIRSTATE: CAZIP CODE:
91763
CAPACITY:24CENSUS: 21DATE:
09/10/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Dina Mopera, AdministratorTIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analysts (LPA's) Pauline Beschorner and Deborah Mullen conducted a case management visit in regards to complaint number 18-AS-20200901113145. LPA's met with Dina Mopera, Administrator at the time of the inspection.

During the initial inspection LPA's observed the facility to be void of carbon monoxide detectors. Therefore in accordance with Title 22 regulations a citation and civil penalty is being issued.

An exit interview was conducted a copy of this report was reviewed with and provided to Administrator Dina Mopera.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Pauline BeschornerTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2020
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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MONTCLAIR GUEST HOME I
FACILITY NUMBER: 360909015
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/11/2020
Section Cited

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1569.311 Carbon Monoxide Detectors Required, Inspection: Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12... This requirement was not met as evidenced by...
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Based on observations the licensee failed to install carbon monoxide detectors as required which poses an immediate health and safety risk to residents in care.
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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: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Pauline BeschornerTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2020
LIC809 (FAS) - (06/04)
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