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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366423658
Report Date: 03/21/2022
Date Signed: 03/21/2022 11:13:39 AM


Document Has Been Signed on 03/21/2022 11:13 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 COTTAGES-VIIIFACILITY NUMBER:
366423658
ADMINISTRATOR:MODY, TRUPTIFACILITY TYPE:
740
ADDRESS:9779 RAMONA AVETELEPHONE:
(909) 625-1231
CITY:MONTCLAIRSTATE: CAZIP CODE:
91763
CAPACITY:6CENSUS: 4DATE:
03/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Bartolomew De Leon, staffTIME COMPLETED:
11:17 AM
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Licensing Program Analysts (LPAs) Anna Bueno and Rayshaun Nickolas made an unannounced visit to the facility. The purpose of the visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. LPAs were met at the door by caregivers and granted entry into the home. LPAs observed all staff are wearing masks. Staff confirmed there are no active and/or suspected COVID positive individuals in the home. Precautionary Covid-19 postings are present at the front door and at the entry point. There is one entry point designated where sign in procedures and screening will occur. The staff temperature screen visitors upon entry into the facility. LPAs observed four (4) residents in the home.

LPAs conducted a brief tour of the facility and made observations pertaining to the facility's infection control measures. The facility was equipped with sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, and has a limited supply of Personal Protective Equipment (PPE).

Based on observations made during today’s inspection, there are no deficiencies being cited per Title 22, Division 6, of the California Code of Regulations. LPAs reviewed this report with and a copy was provided to the facility representative.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2022
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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