366409605-2-20-2024-56-AS-ACON-D2MRP7-20240220121129

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366409605
Report Date: 02/20/2024
Date Signed: 02/20/2024 12:11:38 PM

Document Has Been Signed on 02/20/2024 12:11 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-VI		FACILITY NUMBER:	366409605
ADMINISTRATOR:	MODY, TRUPTI		FACILITY TYPE:	740
ADDRESS:	6619 AMBERWOOD DR		TELEPHONE:	(909) 980-4028
CITY:	ALTA LOMA	STATE: CA	ZIP CODE:	91701
CAPACITY:	6	CENSUS: 1	DATE:	02/20/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Mijo Suzuki, Caregiver		TIME COMPLETED:	12:15 PM

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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Mountain View Cottages - VI unannounced to conduct an Annual Inspection. LPA knocked on the door and was greeted by Caregiver, Mijo Suzuki. LPA introduced self and stated purpose of the visit. LPA was granted entry and signed in. LPA was informed that the current census is 1. Other residents in care had been picked up and taken to their day programs.

LPA was provided a place to work then accompanied by Staff on a walk through of the facility.
The facility is comprised of, six (6) Bedrooms, 2 Bathrooms, Living Room, Den, Office Space, Kitchen, Backyard and attached garage. The facility is a Residential Care Facility Elderly. The facility also maintains partnership with the Inland Regional Center at Level 4I. Facility is approved for 6 non-ambulatory, 1 bedridden and Hospice Waiver approval for 2 residents. The facility is operating in the capacity approved by Community Care Licensing (CCL).

Physical Plant: The facility is maintained in comfortable temperature. Sufficient lighting was provided throughout the facility by various lamps, light fixtures and night-lights. Pathways were free of obstruction and clutter. Smoke detectors and carbon monoxide alarms were observed throughout the facility. They were tested and found operational. A fully charged fire extinguisher was located in the kitchen; last inspection date February 2024. Resident rooms all contained adequate furniture such as: beds with required linens, adequate storage space, seating and sufficient lighting. At approximately 10:40 am LPA observed a yellow colored bottle of pledge sitting unattended in a Resident Room. Staff secured the bottle of pledge upon observation. Extra linens and hygiene supplies were stored in a hallway closet. The hallway lead to the facility's laundry room and attached garage. LPA observed that the garage door was secure. Laundry room also contained secure cabinetry for laundry supplies.

Please see LIC809-C

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2024

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 COTTAGES-VI	FACILITY NUMBER: 366409605
	VISIT DATE: 02/20/2024

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Bathrooms contained operational appliances, handrails, non-slip materials and adequate paper supplies. Both dining rooms, den and living rooms provide adequate seating for residents, guests and visitors. Activity materials were observed in each common space.

Food Service: LPA observed the facility kitchen, which contained operable appliances and sufficient dishware, cups, and utensils for residents in care. The facility food supply was observed to have sufficient amounts of both non-perishable and perishable foods. Inside the facility refrigerator. LPA observed fresh fruit and vegetables, beverages, milk, breads, cheese, frozen meats and meals. Chemicals and Sharp objects were observed in secure locations inaccessible to residents in care. Water temperature was tested in the kitchen and measured between 100 and 104 degrees. Emergency supply of food, water, additional PPE, and supplies were observed in the attached garage. Adjacent to the kitchen stands a secure cabinet for Resident Medications and files.

Signs and Posters: LPA observed the following posters in prominent places throughout the facility. Posters such as: Long Term Care Ombudsman, Resident Council, Resident Rights, House Rules, Facility Sketch/Evacuation Plan, Labor Laws, SEE/SAY, Food Menu, Activities Calendar, Infection Control and Facility License.

Record Review: LPA reviewed resident files for Admission's Agreements, Appraisals, Needs and Services, IPPs and Physician's Report. LPA requested staff records/files. Administrator arrived shortly after request to provide LPA with staff records. Staff records reviewed contained current Health Screenings, Personnel Records, Criminal Background, Fingerprints, CPR/1st Aid and annual required training.

Based on observations, interviews and record reviews no deficiencies will be cited per Title 22, California Code of Regulations. A technical violation will be issued to address an above mentioned concern. An exit interview was conducted where this report was reviewed, discussed, then provided to Facility Representative.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2024

LIC809 (FAS) - (06/04)

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