366423658-5-16-2022-56-AS-ABUO-CEGTLD-20220516144919

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366423658
Report Date: 05/16/2022
Date Signed: 05/16/2022 02:49:24 PM

Document Has Been Signed on 05/16/2022 02:49 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-VIII		FACILITY NUMBER:	366423658
ADMINISTRATOR:	MODY, TRUPTI		FACILITY TYPE:	740
ADDRESS:	9779 RAMONA AVE		TELEPHONE:	(909) 625-1231
CITY:	MONTCLAIR	STATE: CA	ZIP CODE:	91763
CAPACITY:	6	CENSUS: 4	DATE:	05/16/2022
TYPE OF VISIT:	POC	UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Bartoleme De Leon, care provider		TIME COMPLETED:	02:53 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced plan of correction (POC) visit to the facility. This POC was conducted to verify compliance from deficiency citations that were issued on 4/19/2022. LPA met with Bartoleme De Leon, care provider. 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 today's visit, LPA observed Accusations posted by the front door. Two of four resident and/or responsible parties deny receiving a written notice regarding the Accusations. On 4/19/2022, LPA issued a deficiency under Health & Safety Code 1569.38. POC was that Licensee shall post accusations: 8219211401, 8219211401B, 8219211401C and 8219211401D in a conspicuous place and provide written notification to the residents and/or resident's responsible party and local long-term care ombudsman. The following deficiency was not corrected by the POC due date nor at the time of this visit. Civil penalties are being assessed and will continue to accrue until proof of corrections has been submitted. Civil penalties assessed today at the rate of $100 per day and the assessment of $2100 is for the period of 4/26/22 through 5/16/22. Civil penalties will continue to accrue at rate of $100 until the violation is corrected. This assessment will not exceed $100 per 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. ******CONTINUED ON LIC809-C******

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna Bueno	TELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2022

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 2

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: 05/16/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The civil penalty assessment started 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 LIC 809D issued on 4/19/2022 for deficiency cited. Civil Penalties assessed today total $2100.

An exit interview was conducted where this report, LIC 421A (civil penalty assessment forms) and appeal rights were discussed. A copy of all reports and forms were provided to care provider, Bartoleme De Leon.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna Bueno	TELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2022

LIC809 (FAS) - (06/04)

Page: 2 of 2