366409921-9-16-2021-18-AS-MBRN-C6WRTK-20210916131829

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366409921
Report Date: 09/16/2021
Date Signed: 09/16/2021 01:18:33 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 CARE		FACILITY NUMBER:	366409921
ADMINISTRATOR:	ILAGAN, ALEXANDER		FACILITY TYPE:	740
ADDRESS:	9073 OLIVE ST		TELEPHONE:	(909) 822-5174
CITY:	FONTANA	STATE: CA	ZIP CODE:	92335
CAPACITY:	24	CENSUS: 20	DATE:	09/16/2021
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Channe Carlos		TIME COMPLETED:	01:30 PM

NARRATIVE

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Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the facility for the purpose of completing a Health and Safety check. LPA Brown was greeted and granted entrance by Administrator Channe Carlos and explained the purpose of today's visit. Administrator Carlos accompanied LPA Brown on a tour of the inside and outside of the facility.

Residents in care were present during visit. Residents in care appeared to be safe with no imminent health/safety concerns observed. LPA Brown observed no health/safety hazards inside the facility. LPA Brown inspected the outside perimeter of the facility and observed no health/safety hazards. There was sufficient number of staff present at the facility to provide care for residents. LPA Brown inspected facility food supplies and observed an adequate supply of perishable and non-perishable food. LPA Brown observed proper signage throughout the facility, sufficient hand hygiene supplies, cleaning supplies, and a sufficient supply of Personal Protective Equipment (PPE). Sharps, cleaning supplies and medications were locked and inaccessible to residents. The needs of the residents in care appeared to be met during the inspection.

An exit interview was conducted where this report (LIC 809) was discussed and provided to Administrator Channe Carlos.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021

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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