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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 360909015
Report Date: 09/10/2020
Date Signed: 07/09/2021 03:38:17 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/01/2020 and conducted by Evaluator Pauline Beschorner
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200901113145
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
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Dina Mopera TIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Facility is in disrepair
Facility is unclean
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Pauline Beschorner and Deborah Mullen conducted an unannounced visit to the facility to investigate the above allegations. LPA met with Dina Mopera, Administrator. LPA conducted an inspection of the home.

The first allegation states that the facility is in disrepair. LPA's inspected the facility and found that in the kitchen, the sink was leaking water onto exposed wires. The leaky faucent resulted in deteriorated, split and/or water damaged dry wall. This posed an immediate fire risk to residents in care.

The second allegation states the facility is unclean. LPA's observed 1 roach trap with dead roaches in a resident bedroom. LPA's observed 3 bathrooms to have broken tiles under the bathroom sinks, what appeared to be black spots around the top of the shower, and one toliet without a lid but covered by a piece of plywood. LPA's observed 3 air vents covered in dust and dirt.


Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 18-AS-20200901113145
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
CCR
87555(b)(29)
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87555(b)(29) General Food Service Requirements: The following food service requirements shall apply: All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair and free of breaks, open seams, cracks or chips. This regulation was not being met as evidenced by:
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Administrator will call plumber to schedule maintenance on the kitchen sink. Administrator will submit receipts of completed work to LPA.
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Based on observations the licensee did not make repairs and/or maintain the kitchen sink. LPA's observed water leaking onto exposed wires. The leaky faucet caused water damage to drywall and cabinets resulting in deteriorated split and/or water damaged dry wall and cabinets which poses an immediate health and safety risk to residents in care.
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Type A
09/11/2020
Section Cited
CCR
87303(a)
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87303(a) Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This regulation was not being met as evidenced by:
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Administrator will have housekeepers clean the black spots around the tops of the showers, remove and clean all air vents, and dispose of roach bait and dead roaches throughout the facility.
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Based on observations the facility licensee did not ensure that the facility was kept clean, safe and sanitary. LPAs observed black spots around the top of one shower, broken tiles around the 3 bathroom sinks, the top of one toilet missing replaced by a piece of plywood, one roach trap with dead roaches in a resident bedroom, and several layers of dust on at least 3 air vents. This poses an immediate health and safety risk to residents in care.
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Administrator will conduct case management visit to verify black spots have been cleaned, air vents cleaned and roach bait and dead roaches removed from the facility.
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
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20200901113145
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 09/10/2020
NARRATIVE
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Based on LPA's observations, the preponderance of evidence standard has been met. Therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations 87555(b)(29) and 87303(a) are being cited on the attached LIC 9099D.

An exit interview was conducted and 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
LIC9099 (FAS) - (06/04)
Page: 3 of 3