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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366409921
Report Date: 06/10/2021
Date Signed: 06/10/2021 01:42:50 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: 24DATE:
06/10/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Channe Carlos - AdministratorTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility and conducted a Plan of Correction visit to follow up on deficiencies cited on 5/14/21 during a Case Management Visit. LPA Colvin met with Administrator Channe Carlos and advised her of the purpose of today's visit. Below is a summary of what LPA Colvin observed.:

On 5/14/21, the facility was cited for the pavement in the facility's parking lot and outdoor walkways being unsafe due to the large cracks and uneven sections of the pavement. During today's inspection, LPA Colvin observed that while the facility had filled in some of the cracks in the parking lot in the front half of the facility, but that the areas nearer the residential buildings (building 2 and 3) did not appear to have been addressed as there were still multiple areas where horizontal lines of pavement, running across nearly the entire length of the walkway, were at a disparity of at least one inch from the connecting piece of pavement. The facility was given a Plan of Correction date of 5/28/21 to address all hazardous areas of pavement. As of 6/10/21, this Plan of Correction has not been met.

Neither the Administrator nor the Licensee (or any other staff) have reached out to LPA Colvin to request an extension on the Plan of Correction. Additionally, when LPA Colvin brought up issue of areas still being a risk to residents, Administrator Channe Carlos appeared unaware of such areas. LPA Colvin showed the Administrator pictures she took during today's visit and agreed to send them to the Administrator for her reference. LPA Colvin additionally advised the Administrator that the areas photographed are not difficult to see if you walk down the length of the property and look at the ground.

Since the deficiency was not corrected by the Plan of Correction date, LPA Colvin is issuing civil penalties for Failure to Correct, as in accordance with Title 22 Regulation 87761(f) regarding issuance of civil penalties. Civil Penalties are being assessed in the amount of $100 per day since the date the correction was due. Civil Penalties are being issued as follows: $100 x 13 days (5/28/21 - 6/10/21) = $1,300.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2021
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MOUNTAIN VIEW RESIDENTIAL CARE
FACILITY NUMBER: 366409921
VISIT DATE: 06/10/2021
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An exit interview was conducted where this report, civil penalties assessment (LIC421FC), and appeal rights were discussed. A copy of all reports, forms, and appeal rights were provided to Administrator Channe Carlos during the exit interview.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2021
LIC809 (FAS) - (06/04)
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