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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800015
Report Date: 05/06/2022
Date Signed: 05/06/2022 10:35:08 AM


Document Has Been Signed on 05/06/2022 10:35 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507



FACILITY NAME:MOUNTAIN VIEW COTTAGES VIIFACILITY NUMBER:
361800015
ADMINISTRATOR:JASBINDAR SINGHFACILITY TYPE:
740
ADDRESS:917 EAST MESA DRIVETELEPHONE:
(909) 566-4000
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY:6CENSUS: 4DATE:
05/06/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:16 AM
MET WITH:Maria Alvarado - staffTIME COMPLETED:
10:37 AM
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Licensing Program Analyst (LPA) Anna Bueno conducted a case management visit to address issues LPA observed during previous visits on 4/19/22 and 4/25/22. LPA met with care provider Maria Alvarado. Administrator Jasbinder Singh was phoned during the visit.

LPA Bueno visited the property on 4/19/22 for another case management and observed dead roaches in the facility. Administrator stated that the facility was fumigated the day before, 4/18/22. On 4/25/22, LPA conducted another unannounced visit to the property and observed live roaches in the kitchen and roach traps in the kitchen cupboards.

During today's visit, LPA Bueno observed live roaches in the sitting areas near the fireplace and printer tables, and under the kitchen sink. Per call with Administrator Singh, two types of traps were left by the pest control representative from 4/18/22. Per Administrator, one trap is scheduled to be switched out monthly while the other is changed quarterly. This is a potential health and safety risk to residents in care. Refer to LIC-809D for deficiency cited.

An exit interview was conducted with Ms. Alvarado where this report, appeal rights, and LI-809D were discussed.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2022
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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Document Has Been Signed on 05/06/2022 10:35 AM - It Cannot Be Edited

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
, CA 92507


FACILITY NAME: MOUNTAIN VIEW COTTAGES VII
FACILITY NUMBER: 361800015

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/25/2022
Section Cited

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PERSONAL ACCOMODATIONS/SERVICE: The following space and safety provisions shall apply to all facilities: The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.
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This requirement was not met as evidenced by:

LPA observed live roaches in the facility. Interviews with staff and residents LPA interviewed residents confirmed that roaches remain present in the facility.
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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: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 05/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2022
LIC809 (FAS) - (06/04)
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