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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366409921
Report Date: 03/08/2024
Date Signed: 03/08/2024 02:22:42 PM


Document Has Been Signed on 03/08/2024 02:22 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 RESIDENTIAL CAREFACILITY NUMBER:
366409921
ADMINISTRATOR:ILAGAN, ALEXANDERFACILITY TYPE:
740
ADDRESS:9073 OLIVE STTELEPHONE:
(909) 822-5174
CITY:FONTANASTATE: CAZIP CODE:
92335
CAPACITY:24CENSUS: 23DATE:
03/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Rosy RiveraTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst's (LPAs) Paola Guerrero and Ryan Gardner made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Facility Caregiver Rosy Rivera and was granted entry to the facility. At the time of the visit there was four (4) staff present, and thirteen (14) residents present and eight (8) residents were out in the community. The facility is a Residential Care Facility for Elderly (RCFE) Licensed capacity is (24) current census (23). LPA was accompanied by Facility Administrator Joney and Caregiver Rosy, to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). While conducting a walk through of the facility LPAs observed facility vent to be covered with accumulating dust. LPAs also observed two resident bathrooms to have broken tiles. In addition, LPAs observed black build-up on bathroom tile and ceiling. Water temperature in building #1 measured at 130.9 exceeding regulation requirements. LPAs observed that facility did not have skid mats in restrooms. During walk through LPAs observed that facility has two separte buildings with no signal systems facility has a census of 23 residents. LPA inspected resident’s bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. During walk through LPAs observed Cleaning supplies such as bleach to be accessible to residents, LPAs had caregiver secure bleach by locking laundry room door. There was a designated storage space for resident/staff files. Medications are kept inside staff office inaccessible to residents in care.

Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. While completing food inspection LPAs observed expired canned jalapenos along with diced green chili cans.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola GuerreroTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2024
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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Document Has Been Signed on 03/08/2024 02:22 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 RESIDENTIAL CARE

FACILITY NUMBER: 366409921

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 03/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by leaving bleach chemicals accessible for residents in care, which poses an immediate health, safety, or personal rights risk to persons in care.
POC Due Date: 03/09/2024
Plan of Correction
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Licensee has agreed to go ever regulation and provide traning on how to properly secure disinfectants, cleaning solutions, poisons, and other items which could pose a danger to residents in care. Licensee shall provide a sign and date training of underestaing to LPA Guerrero on POC date 3/9/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola GuerreroTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/08/2024 02:22 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 RESIDENTIAL CARE

FACILITY NUMBER: 366409921

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 03/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in the facility shall be clean, safe, sanitary and in good repair. LPAs observed building #1 vent to be covered with accumilating dust. which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/11/2024
Plan of Correction
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Licensee has agreed to read over regulation and provide pictures proof that the bathroom has been repaired/ sanitized and cleaned. Licensee has agreed to clean air duct in building #1 and provide pictures of completion to LPA by POC date 3/11/2024.
Type B
Section Cited
CCR
87303(a)(1)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPAs observed two resident bathrooms to have broken tiles. In addition, LPAs observed black build-up on bathroom tile and ceiling. which poses a potential health, safety, or personal rights risk to persons in care.which poses a potential health, safety or personal rights risk to persons in care.

POC Due Date: 03/22/2024
Plan of Correction
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Licensee has agreed to read over regulation and provide pictures proof that the bathroom has been repaired/ sanitized and cleaned. Licensee has agreed to provide sanitation training to LPA on POC date 4/1/2024.
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: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola GuerreroTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/08/2024 02:22 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 RESIDENTIAL CARE

FACILITY NUMBER: 366409921

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 03/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPAs measured water in bathroom located in building #1 and observed water temperature to measure at 130.9 which pose a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/11/2024
Plan of Correction
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Licensee has agreed to adjust water temperature to meet the required temperature of 105/120 f based on regulation and provide pictures of completion to LPA Guerrero by POC date 3/11/2024.
Type B
Section Cited
CCR
87303(e)(5)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above. LPAs observed that facility did not have skid mats in restrooms which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/11/2024
Plan of Correction
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Licensee has agreed to purchase skid mats for all residents restrooms and provide pictures along with recipts to LPA Guerrero upon completion by POC date 3/11/2024
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: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola GuerreroTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2024
LIC809 (FAS) - (06/04)
Page: 4 of 7


Document Has Been Signed on 03/08/2024 02:22 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 RESIDENTIAL CARE

FACILITY NUMBER: 366409921

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 03/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(i)(1)
Maintenance and Operation
(i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPAs observed that facility has two separte buildings with no signal systems facility has a census of 22 residents. which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2024
Plan of Correction
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Licensee has agreed to install signal systems for both buiding #1 and Building #2. Administrator will provide pictures along with recipts upon completion to LPA Guerrero on POC date 3/29/2024
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPAs observed expired canned jalapenos along with diced green chili cans. Which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/22/2024
Plan of Correction
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Licensee has agreed to read over the regulation and provide nutrition training for all staff regarding food storage. Licensee shall provide a signed and dated document of traning to LPA Guerrero upon completion by POC date 3/22/2024
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: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola GuerreroTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2024
LIC809 (FAS) - (06/04)
Page: 5 of 7


Document Has Been Signed on 03/08/2024 02:22 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 RESIDENTIAL CARE

FACILITY NUMBER: 366409921

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 03/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(b)(1)

87303 (b) A comfortable temperature for residents shall be maintained at all times... (1) The facility shall heat rooms that residents occupy to a minimum of 68-degree F, (20 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, the licensee did not comply with the section cited above. LPAs observation heating pilot was not lit. Which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/11/2024
Plan of Correction
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Licensee has agreed to fix pilot and provide pictures/recipts upon completion to LPA on POC date 3/11/2024.
Type B
Section Cited
CCR
87307(a)
87307 (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply:


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. By converting the entry way into an enclosed office and blocking main exterior exit door. Which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/09/2024
Plan of Correction
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Licensee has agreed to read over the entire regulation and remove all office items from entry way to ensure all emergency exits are clear of obstruction. Licensee will provide pictures and email all picures upon completion to LPA Guerrero by POC 3/9/2024.
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: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola GuerreroTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2024
LIC809 (FAS) - (06/04)
Page: 6 of 7


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 RESIDENTIAL CARE
FACILITY NUMBER: 366409921
VISIT DATE: 03/08/2024
NARRATIVE
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Record Review: LPAs reviewed five(5) resident files for admission agreements, updated physician reports, and needs and services plans. LPAs also reviewed five (5) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. Medications were audited at random and appeared to be dispensed appropriately by staff members.

Based on the observations made during today’s visit, eight (8) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809),(809D), along with appeal rights were provided to Facility Caregiver Rosy Rivera at the end of the visit.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola GuerreroTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024
LIC809 (FAS) - (06/04)
Page: 7 of 7