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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366423658
Report Date: 04/19/2022
Date Signed: 04/19/2022 04:23:35 PM


Document Has Been Signed on 04/19/2022 04:23 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 COTTAGES-VIIIFACILITY NUMBER:
366423658
ADMINISTRATOR:MODY, TRUPTIFACILITY TYPE:
740
ADDRESS:9779 RAMONA AVETELEPHONE:
(909) 625-1231
CITY:MONTCLAIRSTATE: CAZIP CODE:
91763
CAPACITY:6CENSUS: 4DATE:
04/19/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:32 PM
MET WITH:Bartolome De Leon, care providerTIME COMPLETED:
04:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Anna Bueno conducted a case management visit to verify compliance with Health & Safety Code Section 1569.38. LPA met with two (2) care providers and phoned administrator Jasbinder Singh, who arrived at the facility shortly.

Health & Safety Code 1569.38 requires the licensee to provide written notification to a resident, the residents' responsible party, if any, and the local long-term care ombudsman within 10 days from the date indicated on the accusation. The licensee is also required to post the accusation in a conspicuous place in the facility.

The date the Accusation was delivered was on 4/8/2022. The licensee had 10 days from this date to notify, in writing, the residents, their responsible parties, and the ombudsman. The 10th day was 4/18/2022.

During the tour of the facility, LPA observed that the facility did not post, as required by law, the accusations: #8219211401, #8219211401B, #8219211401C and #8219211401D at the front entrance of the facility. During the visit at Mountain View Cottage VII, Licensee telephonically stated she has not informed residents, or their responsible parties, or the local ombudsman in writing of the legal proceedings against the facility. During today's visit, Administrator Jasbinder Singh arrived and the accusations: #8219211401, #8219211401B, #8219211401C, #8219211401D were posted on the

During today’s visit, LPA observed and/or the Administrator confirmed that:
  1. The facility posted accusations: #8219211401, #8219211401B, #8219211401C and #8219211401D, as required by law.
  2. The facility failed to provide written notification as required by H&S Code 1569.38(b) to the residents/resident's responsible party within the required 10 days.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2022
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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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 COTTAGES-VIII
FACILITY NUMBER: 366423658
VISIT DATE: 04/19/2022
NARRATIVE
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A civil penalty is being assessed for a violation of Health & Safety Code (b). Civil penalties shall be assessed until violation is corrected. Per California Health & Safety Code section 1569.38, you are hereby notified that a $100 civil penalty per day will be assessed until the violation is corrected. This assessment will not exceed $100/day regardless of the number of notices the licensee fails to send. The total civil penalty for a continuous violation shall not exceed $5,000. The civil penalty assessment starts on 04/19/2022 and continues until Licensing has received proof that all required parties have received written notification of the revocation action.

Refer to LIC809D for deficiency cited. A civil penalty of $100.000 was assessed on 4/19/2022.

An exit interview was conducted where this report was provided to Jasbinder Singh, administrator.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 04/19/2022 04:23 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 COTTAGES-VIII
FACILITY NUMBER: 366423658

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/19/2022
Section Cited

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POSTING OF LICENSING REPORTS; DISCLOSURE TO NEW RESIDENTS: Requires the licensee of a residential care facility for the elderly to provide written notification to the residents, resident's responsible party (if any) and to the local Long-Term Care Ombudsman within 10 days..: The Department of Social Services commences proceedings to suspend or revoke the license of the facility. This occurs when the accusation is served to the respondent.
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This requirement was not met as evidenced by:
Licensee verified that they have not provided written notification as required...to the residents/resident's responsible party, and Ombudsman.
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The facility was issued a civil penalty of $100 a day which is imposed until the facility complies with a maximum of $5000.

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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: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2022
LIC809 (FAS) - (06/04)
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