<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880629
Report Date: 08/03/2021
Date Signed: 08/03/2021 12:16:06 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:MOUNTAIN VIEW FAMILY HOME INCFACILITY NUMBER:
361880629
ADMINISTRATOR:KOUDSI, ABDULLAHFACILITY TYPE:
735
ADDRESS:2047 N PALM AVETELEPHONE:
(909) 204-2398
CITY:UPLANDSTATE: CAZIP CODE:
91784
CAPACITY:6CENSUS: 2DATE:
08/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Najiba KoudsiTIME COMPLETED:
12:21 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPAs) Anna Bueno and Shaunte Henry made an unannounced visit to the facility. The purpose of the visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. LPAs were granted entry by administrators Abdullah Koudsi and Najiba Koudsi and LPAs explained the purpose of today's visit.

During the inspection, LPAs conducted a brief tour of the facility and made observations pertaining to the facility's infection control measures. The facility was also equipped with sufficient hand hygiene supplies, sufficient cleaning/disinfecting provisions, and a 30+ day supply of Personal Protective Equipment (PPE). LPAs Bueno and Henry also observed that all staff members were properly wearing face coverings. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the proper use and disposal of PPE. The facility continues to monitor client regularly for their temperature, any changes in condition, and notify the client's physician and emergency personnel in the event the client presents any COVID-19 symptoms.

LPAs Henry and Bueno observed no health and safety concerns at the time of visit. Based on observations made during today’s inspection, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted where this report was discussed and a copy of this report was also provided to Ms. Koudsi.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021
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 1