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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366409921
Report Date: 05/14/2021
Date Signed: 05/14/2021 03:20:01 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 RESIDENTIAL CAREFACILITY NUMBER:
366409921
ADMINISTRATOR:ILAGAN, ALEXANDERFACILITY TYPE:
740
ADDRESS:9073 OLIVE STTELEPHONE:
(909) 822-5174
CITY:FONTANASTATE: CAZIP CODE:
92335
CAPACITY:24CENSUS: 22DATE:
05/14/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Channe Carlos - AdministratorTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility in investigate allegations related to a complaint (#18-AS-20210505121329), during which LPA Colvin observed the following deficiencies:

While interviewing residents, LPA Colvin was made aware of one of the two bathrooms in building #1 being out of order due to having a broken toilet seat. LPA Colvin was informed by numerous residents that the toilet had been in this condition for at least one week, which was causing disruptions with being able to use the restroom, as they were all now having to share the single toilet in building #1, or use the toilet in another building if it was not clogged. LPA Colvin observed that the washroom in which the broken toilet was held was marked off limits with a paper sign on the door, and caution tape around the door, blocking entrance. One of the staff members came to replace the toilet seat once the issue was brought to the attention of the Administrator, and was able to be replaced during today's visit, as the facility had a new toilet seat on hand already. A deficiency is being cited due to the facility having one of four bathrooms out of order for at least one week. The facility is licensed for 24 residents and has four bathrooms, as required by Title 22 Regulations. With one bathroom out of order, the facility thus fails to ensure there are enough operational bathrooms for the residents in care. Deficiency cited.

LPA Colvin continued to tour the facility and observed in two of the three bathrooms that were still available to resident use (LPA Colvin did not check the third bathroom) that there was no toilet paper, paper towels, or hand soap in the bathroom. LPA Colvin interviewed some of the residents and asked them about how they are able to wash their hands after they use the restrooms, and every resident interviewed stated that they couldn’t unless they purchased their own supplies. LPA Colvin asked Administrator Channe Carlos about the situation, and she stated that they were available on request and provided to residents individually on a daily basis, due to resident's misuse. LPA Colvin requested to see the facility's storage of sanitary hygiene items and was able to confirm that the facility did have a sufficient supply for immediate use.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2021
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 RESIDENTIAL CARE
FACILITY NUMBER: 366409921
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/14/2021
Section Cited

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Maintenance and Operation: (e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition.... This requirement was not met as evidenced by:
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Based on LPA Colvin's interviews and observations, the Licensee did not comply with the above regulation with at least one of four bathrooms. One of the two bathrooms in building #1 was sealed off from residents due to needing repairs. This poses a potential personal rights violation to all residents.
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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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 05/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 RESIDENTIAL CARE
FACILITY NUMBER: 366409921
VISIT DATE: 05/14/2021
NARRATIVE
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LPA Colvin asked some residents again about if soap and paper products were available upon request, but the residents re-interviewed did not appear to understand the question and maintained that they must wait for whenever staff "feel like" putting more in the restroom. From LPA Colvin's interviews and observations, it appears that hand hygiene products, such as paper towels and soap, are not readily available for resident's use, unless they have the forethought to request such items. Deficiency cited.

While touring the facility, LPA Colvin observed numerous areas of the pavement and asphalt surrounding the buildings to be in disrepair and uneven. Through interviews LPA Colvin learned that a resident (R1) had recently fallen or tripped on the uneven pavement and was now injured. LPA Colvin located R1 and observed R1 to have a bruised hand and a dressing on their knee from the hospital, where they were treated from the fall. LPA Colvin asked Administrator Channe about the uneven asphalt and pavement and the danger that it posed to residents. Administrator Channe stated that it was not a major hazard to the residents as R1 was the only resident to have fallen. LPA Colvin inquired about getting the ground fixed, and Administrator Channe stated that she would need to talk to maintenance to see about getting it repaired. The uneven ground and holes in the asphalt and pavement are an immediate safety hazard to residents, as observed by R1's recent fall and subsequent injury. Deficiency cited.

Due to LPA Colvin's observations, deficiencies were cited. An exit interview was conducted, and a copy of this report was provided to Administrator Channe Carlos.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 RESIDENTIAL CARE
FACILITY NUMBER: 366409921
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/28/2021
Section Cited

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Personal Accommodations and Services: (d) The following space and safety provisions shall apply to all facilities: (2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement was not met as evidenced by:
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Based on LPA Colvin's observations and interviews, the Licensee did not comply with the above regulation with at least one area of the facility (asphalt/pavement surrounding buildings). This poses an immediate safety risk to all residents in care, as R1 recently fell due to the uneven ground.
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Type A
05/17/2021
Section Cited

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Personal Accommodations and Services: (a) Living accommodations...shall be related to the facility's function...The following provisions shall apply:(3) Equipment and supplies necessary for personal care and...adequate hygiene practice shall be readily available...(D) Hygiene items of general use such as soap and toilet paper.
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This requirement was not met by: Based on LPA Colvin's observations and interviews, the Licensee did not comply with the above regulation in at least 2 out of 4 bathrooms. Residents report not having access to hand soap and paper towels, which LPA Colvin observed. This is an immediate health risk.
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located in each bathroom, as well as provide LPA Colvin with their plan for addressing issues with certain residents misusing (overusing) hand hygiene products, and how this will not infringe on rights of other residents. Plan of correction due 5/17/21.
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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 05/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4