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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366409921
Report Date: 06/23/2022
Date Signed: 06/23/2022 10:39:34 AM


Document Has Been Signed on 06/23/2022 10:39 AM - 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: 21DATE:
06/23/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Nancy KellerTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Melody Brown arrived unannounced at the facility 06/23/2022 at 09:30 AM for the purpose of a Plan of Correction (POC) visit. LPA Brown met with staff Nancy Keller and LPA Brown explained the purpose of the visit. Administrator Channe Carlos was contacted and informed of the visit.

On 03/24/2022 the facility was issued a deficiency with a plan of correction date on 04/21/2022. On 04/21/2022, Administrator Channe Carlos had submitted a request for a POC extension to reflect as 06/21/2022 due to the amount of work that needs to be done and its cost. LPA Brown approved the requested POC date to now reflect as 06/21/22. Per Plan of Correction issued, the licensee stated to repair and level the concrete pavement/walkway located between building 1 and building 2. During the visit, LPA Brown conducted a physical plant assessment of the plan of correction. LPA Brown toured the facility and observed new concrete pavement between building 1 and building 2 and LPA Brown noticed that the pavement floor was leveled. LPA Brown has determined that the plan of correction has been met.

Facility will receive a Letter of Deficiency Citation Cleared for the deficiency cleared during inspection.

An exit interview was conducted where this report (LIC809) was discussed and provided to staff Nancy Keller.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2022
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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