361880853-3-4-2024-56-AS-MMAE-D332KU-20240304162830

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361880853
Report Date: 03/04/2024
Date Signed: 03/04/2024 04:28:49 PM

Document Has Been Signed on 03/04/2024 04:28 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 PLEASANT LIVING		FACILITY NUMBER:	361880853
ADMINISTRATOR:	KARA RICHARDSON		FACILITY TYPE:	740
ADDRESS:	2258 MENTONE BLVD		TELEPHONE:	(909) 810-1500
CITY:	MENTONE	STATE: CA	ZIP CODE:	92359
CAPACITY:	20	CENSUS: 16	DATE:	03/04/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:55 AM
MET WITH:	Elizabeth Mahan - Administrator		TIME COMPLETED:	04:30 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 Analyst (LPA) Magda Malcore conducted and unannouced required annual inspection. LPA met with Elizabeth Mahan, Administrator, and discussed the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) with a license capacity of (20) and a current census of (16) residents in care. LPA conducted an overall inspection of the facility, which included, but was not limited to, the following: Physical Plant/Environment: Indoor and outdoor passageways are free of obstruction. The facility has no swimming pools or similar bodies of water. Indoor and outdoor activity space is sufficient for resident in care. The facility's outdoor activity space is gated and protected from traffic. The facility has sufficient lighting and is maintained at a comfortable temperature. Resident’s showers, toilets, and hand washing areas were operating in a safe and sanitary condition. The bathrooms were equipped with grab rails and non-skid flooring. The hot water temperature in residents' bathrooms measured at 110 degrees F. Nine (9) Resident’s bedrooms inspected were equipped with beds, bed linen, chairs, and lighting. The facility has operating carbon monoxide alarms, telephone service, laundry equipment and signal system. The facility has sufficient linen and personal hygiene items for residents. The facility has posted in a common area, Community Care Licensing complaint poster, Ombudsman poster, Personal Rights, Theft and Loss Policy, disaster evacuation exit plans and emergency telephone numbers. Sharps, disinfectants, and cleaning solutions were kept locked and inaccessible to residents in care. Care & Supervision: Facility has 24-hour, 7 days a week care staff.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2024

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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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 PLEASANT LIVING	FACILITY NUMBER: 361880853
	VISIT DATE: 03/04/2024

NARRATIVE

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Food Service: Facility kitchen and dining areas are maintained clean. The facility has sufficient non-perishable and perishable food supply for residents in care; However, one of the facility's freezers used to store perishable food items was not maintained at a temperature of 0 degree F. The freezer tested at 28 degrees F. The Administrator moved the perishable items out of the freezer into another properly operating freezer and stated the she will have the refrigerator serviced. Deficiency cited.
Record Review: LPA review of five (5) staff files and five (5) resident files reveals the following: staff #1 (S1) did not have a health screening signed by the examining physician. Resident #1 (R1) did not have a current physician's reports or medical assessment conducted within 12 months on file as required due to R1's cognitive condition. The facility’s liability insurance is current. The facility’s last fire drill was conducted on 12/21/23.
Medical Related Services: Resident’s medications are labeled and centrally stored in a locked room. The facility has a complete first aid kit.

Based on observations and record review, deficiencies are being cited per Title 22, of the California Code of Regulations. An exit interview was conducted where the Licensing reports were reviewed and copies with Appeal Rights were provided to Administrator Mahan at the conclusion of the visit.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/04/2024 04:28 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 PLEASANT LIVING	FACILITY NUMBER: 361880853
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87555(b)(21)

General Food Service Requirements

(b) The following food service requirements shall apply: (21) Freezers of adequate size shall be maintained at a temperature of 0 degree F (-17.7 degree C), and refrigerators of adequate size shall maintain a maximum temperature of 40 degree F. (4 degree C). They shall be kept clean and food stored to enable adequate air circulation to maintain the above temperatures. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observations, the licensee did not comply with the section cited above by one of the facility's freezers was not maintained at 0 degree F, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/11/2024
	Plan of Correction
1 2 3 4	The Licensee/Administrator shall submit to the Licensing Agency proof of freezer operating within regulation temperature by POC due date.

Section Cited

Managed Incontinence


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/04/2024 04:28 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 PLEASANT LIVING	FACILITY NUMBER: 361880853
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87506(a)

Resident Records

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observations, the licensee did not comply with the section cited above by Resident #1 (R1) did not have a current physician's report or medical assessment conducted within 12 months on file as required due to R1's cognitive condition; which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/31/2024
	Plan of Correction
1 2 3 4	The Licensee/Administrator shall submit to the Licensing Agency a current physician's report/medical assessment by POC due date.

Type B

Section Cited

CCR

87411(f)

Personnel Requirements: All personnel...shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test performed by a physician...A report shall be made of each screening, signed by the examining physician...This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA record review, the licensee did not comply with the section cited above by staff #1 (S1) did not have a health screening signed by the examining physician on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/31/2024
	Plan of Correction
1 2 3 4	The Licensee/Administrator shall submit to the Licensing Agency a physician signed health screening for S1 by POC due date.

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 Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2024

LIC809 (FAS) - (06/04)

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