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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800015
Report Date: 08/04/2023
Date Signed: 08/04/2023 04:06:47 PM


Document Has Been Signed on 08/04/2023 04:06 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, 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: 5DATE:
08/04/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jasbinder Singh, AdministratorTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst, Amber Coleman, (LPA) made an unannounced complaint visit for complaint 56-AS-20230802121927. It was during this visit, LPA observed deficiencies not related to the complaint allegations.

Upon LPA's arrival, LPA met with staff to discuss the residents in care. LPA asked a number of questions to staff. Staff's response to questions was limited and did not provide LPA with enough information. Staff expressed, that she doesn't know a lot of English and needs assistance with interpretation.

At approximately 10:15am, while observing the facility's backyard. LPA observed a third party contractor making repairs to the facility's unattached garage roof. LPA observed materials from the roof were being pulled from the roof and dropped onto the ground. Some of the materials had nails still attached. LPA spoke with Administrator and learned that no report was sent to Community Care Licensing to notify about construction taking place at the facility. The contractor reported that he is repairing the roof of the garage and the facility itself. The expected date they will finish is over the weekend (August 5th and 6th, 2023) The materials, power tools out and ladders are not secure, allowing residents access; which poses a potential threat to residents in care.

At approximately 10:17am, while observed the facility's backyard, LPA observed open containers of chemicals and toxins. LPA observed a bottle of pesticides sitting on the ground near the sliding door to access backyard. On the patio, LPA observed a standing barbecue. Adjacent to the barbecue, LPA observed an open container of lighter fluid.

Please see LIC809C


SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


Document Has Been Signed on 08/04/2023 04:06 PM - 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: MOUNTAIN VIEW COTTAGES VII
FACILITY NUMBER: 361800015

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/04/2023
Section Cited
CCR
87305(a)

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Alterations to Existing Building or New Facilities: (a) Prior to construction or alterations, all facilities shall obtain a building permit.
This requirement was not met as evidenced by:
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Administrator agrees to complete a Special Incident Report to report the damages to the facility, what should be fixed and the projected date of completion to the Community Care Licensing Office within the next 30 days. Administrator will also submit a statement of understanding by way of a LIC9098.
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Based on observations and interviews, the Administrator failed to notify Community Care Licensing that the facility roof was damaged and required repairs. This poses a potential health, safety, or personal rights risk to residents in care.
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Type B
09/04/2023
Section Cited
CCR87411(d)(3)

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87411 (d)(3) Personnel Requirements
(3) Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents.
This requirement is not met as evidenced by:
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Administrator will seek and hire staff members who have the skills and knowledge to effectively communicate with staff and residents alike. Administrator agrees to do so within the next 30 days and submit proof of correction to the Community Care Licensing.
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Based on observations and interviews, the Administrator did not ensure that all staff have skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents, which poses a potential health, safety, and personal rights risk to persons 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: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 08/04/2023 04:06 PM - 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: MOUNTAIN VIEW COTTAGES VII
FACILITY NUMBER: 361800015

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/07/2023
Section Cited
CCR
87309(a)

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87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
This requirement was not met as evidenced by:
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Administrator instructed staff to locate all chemicals left out and place them in a secure place inaccessible to resident's. LPA observed the staff collect all containers and place them in a secure place. The plan of correction has been completed during visit.
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Based on observations, the Administrator failed to ensure that all toxins and chemicals are kept inaccessible. This poses a potential health, safety or personal rights risk to residents in care.
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Type A
08/07/2023
Section Cited
CCR87405(a)

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87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator.
This requirement was not met as evidenced by.
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Administrator agrees to locate documentation that the Administrator Certification course has been completed and awaiting the certificate. Administrator will submit verification to community care licensing no later than Monday 8/7/23 by close of business.
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Based on record reviews and interviews, the Administrator failed to designate an Administrator for the facility when her Administrator Certificate expired. This poses a potential health, safety and personal rights 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: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MOUNTAIN VIEW COTTAGES VII
FACILITY NUMBER: 361800015
VISIT DATE: 08/04/2023
NARRATIVE
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At approximately 10:19am, while observing the walkways outside facility. LPA observed a cat seated on the patio. Next to the cat was a bowl of animal food. LPA walked to the right of the facility to observe a staff member placing cat food outside the bedroom. Next to the food, stood an animal crate. When LPA inquired about the stray cats. Staff denied that they put food out for stray cats; stating that the residents feed stray cats. LPA had a discussion with staff and the Administrator to address the concern for stray cats in or around the facility and the impact the stray cats may have on residents in care. Administrator and staff stated they understood.

At approximately 11:57am, LPA reviewed staff files and observed that there was no valid Administrator on file for the facility.

Based on observations and interviews made during today’s inspection, deficiencies will be cited per Title 22, Division 6, of the California Code of Regulations CCR). An exit interview was conducted and a copy of this report, LIC 809D, and Appeal Rights were given to the Licensee.

SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4