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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800015
Report Date: 06/01/2022
Date Signed: 06/01/2022 03:21:43 PM


Document Has Been Signed on 06/01/2022 03:21 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
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: 6DATE:
06/01/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:42 PM
MET WITH:Monica Cepena, care staffTIME COMPLETED:
03:23 PM
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Licensing Program Analyst (LPA) Anna Bueno conducted a Plan Of Correction (POC) visit to address an issue LPA Bueno observed during a previous visits on 5/6/22, 4/25/22, and 4/19/22. LPA met with care provider Monica Cepena who was informed of the purpose of today's visit.

LPA Bueno visited the property on 4/19/22 on a separate case management concern 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. On 5/6/22, LPA observed live roaches in the facility. Administrator Singh confirmed that the facility was fumigated in February 2022 and on 4/18/22. Administrator sent a photo of a pest control treatment invoice dated 5/11/22 to LPA Bueno's cell phone on 5/24/22

During today's visit LPA Bueno toured the outside and LPA and staff toured the inside of the facility. LPA and staff observed no live pests in the facility.

An exit interview was conducted with Ms. Cepena and this report was discussed and a copy provided.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2022
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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