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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366409921
Report Date: 03/24/2022
Date Signed: 03/24/2022 02:04:54 PM


Document Has Been Signed on 03/24/2022 02:04 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, 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: 20DATE:
03/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Channe CarlosTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Melody Brown arrived at the facility 03/24/2022 at 09:30 AM unannounced in order to complete the facility's Annual Inspection. LPA Brown met with Staff 2 and LPA Brown advised Staff 2 of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. Administrator Channe Carlos was contacted and arrived at the facility during the visit. Below is a summary of what was observed:

Infection Control: LPA Brown went over COVID-19 best practices for infection control and prevention with Administrator Channe Carlos and per file review, Mitigation Plan was submitted 04/2021. LPA Brown observed the facility having Covid-19 signages throughout the facility for proper hand washing procedure and social distancing. LPA Brown toured the facility and observed that resident bathrooms have hand soap and Administrator Carlos reported that each resident was provided with clean hand towel everyday. LPA Brown requested to inspect the facility's Personal Protective Equipment (PPE) supply. LPA Brown observed the facility to have a sufficient supply of sanitizer, gloves, masks, isolation gowns, face shields/goggles.

LPA Brown went over the various recommended training for facility staff with Administrator Channe Carlos in relation to COVID-19 and Administrator Channe Carlos reported that all staff were trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing of PPE. During the visit, LPA Brown observed no routine symptom screening/temperature check has been initiated at entry for all staff, residents and visitors. LPA Brown will be issuing a deficiency as this practice has a health and safety impact that includes, but is not limited to personal rights, health related services and personnel requirements.



*** Continuation in LIC809C *****
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2022
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 10


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
, CA 92507
FACILITY NAME: MOUNTAIN VIEW RESIDENTIAL CARE
FACILITY NUMBER: 366409921
VISIT DATE: 03/24/2022
NARRATIVE
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LPA Brown inquired as to if staff have been fit tested for N95 masks, and Administrator Channe Carlos informed LPA Brown that at this time staff have not been fit tested. LPA Brown will be issuing a deficiency for this item due to the facility recently have a COVID-19 positive resident last 02/07/2022, and N95 masks needs to be worn when a resident is COVID-19 positive or under observation while awaiting test result. Also, LPA Brown observed that most residents and staff have been vaccinated and are practicing other COVID-19 precautions. LPA Brown informed Administrator Channe Carlos the information for Provider Information Notice (PIN) PIN-21-10-ASC which contains resources for getting staff fit tested for N95 masks.

The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities. The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and their residents for COVID-19, when and how to isolate/quarantine resident, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas. The facility also has a plan in place to monitor their residents regularly for any changes in condition and to subsequently notify the resident's physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses.

Throughout today's inspection, LPA Brown observed Administrator Channe Carlos, Staff 2 (S2) and Staff 3 (S3) to not wearing mask. As of today's date, Community Care Licensing is still recommending for all staff to continue to wear a mask when inside the facility. LPA Brown requested Administrator Carlos, S2 and S3 to wear a mask during the visit. LPA Brown will be issuing a Technical Assistance Advisory Note for staff not wearing masks while inside the facility. LPA Brown additionally observed a resident to not be wearing a mask either, and LPA Brown advised Administrator Carlos to encourage the residents to wear masks when in common areas indoors, though they cannot be forced.

LPA Brown reviewed facility roster and observed that Staff 4 (S4) is not associated at the facility. Administrator Carlos reported that she’s having problem accessing her account to associate S4 at the facility and contacted customer service during the visit. LPA Brown will be issuing a technical violation for failure to associate employee at the facility.

**** Contiuation in LIC809C ***

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2022
LIC809 (FAS) - (06/04)
Page: 2 of 10
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
, CA 92507
FACILITY NAME: MOUNTAIN VIEW RESIDENTIAL CARE
FACILITY NUMBER: 366409921
VISIT DATE: 03/24/2022
NARRATIVE
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 During the visit, LPA Brown observed no carbon monoxide detector in the second (2nd) building. Administrator Carlos reported that they will purchase carbon monoxide detectors today. LPA Brown will be issuing a deficiency. In addition, LPA Brown noticed that most windows do not have screen and some window blinds are in disrepair. Administrator Carlos reported that they will install the missing windows screens and blinds. Moreover, LPA Brown observed the facility concrete floor located along the walkway from the 1st building to the 2nd building walkway of the facility were not leveled and a fall hazard for residents in care. There are holes and and cracks on concrete floors. LPA Brown will be issuing a deficiency as it poses a potential risk to residents in care.

In addition, LPA Brown noticed a construction at the facility and Administrator Carlos reported that she was told it was an office space or a storage space. LPA Brown inquired if there's a building permit obtained and House Manager Nenita Carlos reported that there's no building permit now but she will obtain a building permit this week. LPA Brown will be issuing a deficiency for not obtaining a building permit prior to construction.

An exit interview was conducted with Administrator Channe Carlos and a copy of this report (LIC809), LIC809D, LIC9102 AN Technical Violation, LIC9102 AN Advisory Notes and Appeal Rights were discussed and provided.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2022
LIC809 (FAS) - (06/04)
Page: 3 of 10
Document Has Been Signed on 03/24/2022 02:04 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: MOUNTAIN VIEW RESIDENTIAL CARE
FACILITY NUMBER: 366409921

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above by not having carbon monoxide detector in building 2 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2022
Plan of Correction
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Licensee stated that they will purchase a carbon monoxide detectors today and install it at building 2. Licensee will send proof of purchase/installation to LPA Brown by POC due date.
Type B
Section Cited
CCR
87303
All window screens shall be clean and maintained in good repair.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above by not having the window screens and window blinds in good repair which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/07/2022
Plan of Correction
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Licensee stated that they will install new window screens and new window blinds at the facility and submit proof to LPA Brown by POC due date.

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: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2022
LIC809 (FAS) - (06/04)
Page: 4 of 10


Document Has Been Signed on 03/24/2022 02:04 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: MOUNTAIN VIEW RESIDENTIAL CARE
FACILITY NUMBER: 366409921

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/24/2022

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

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provisionof 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 and interview, the licensee did not comply with the section cited above by not having the concrete floor located between building 1 and building 2 walkway in good repair and leveled which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/21/2022
Plan of Correction
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LIcensee stated that they will complete the concrete floor repair to level it and repair the floor cracks and holes between building 1 and building 2 walkway and submit proof of repair to LPA Brown by POC due date.
Type B
Section Cited
HSC
130
Licensee has provided all staff who are working with Covid-19 positive resident with fit-testing for N95 respirators. This practce has a health and safety impact that includes, but is not limited to, personal rights, buildings and grounds, and responsibility for providing care and supervision.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, , the licensee did not comply with the section cited above by not providing staff with N95 Fit test which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/21/2022
Plan of Correction
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Licensee stated that all staff will be provided N95 Fit test and they will submit proof of completion to LPA Brown by POC due date.

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: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2022
LIC809 (FAS) - (06/04)
Page: 8 of 10


Document Has Been Signed on 03/24/2022 02:04 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: MOUNTAIN VIEW RESIDENTIAL CARE
FACILITY NUMBER: 366409921

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
121125,120140,120276


This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not not having routine symptom screening and temperature check initiated at the entry for all staff and visitors which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2022
Plan of Correction
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Licensee stated that they will have routine symptom screening and temperature check initiated at the entry for all staff and visitors today and submit proof of completion to LPA Brown by POC due date.
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: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2022
LIC809 (FAS) - (06/04)
Page: 10 of 10