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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366423658
Report Date: 04/14/2023
Date Signed: 04/14/2023 01:13:52 PM


Document Has Been Signed on 04/14/2023 01:13 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, 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: 5DATE:
04/14/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Helen Nova, CaregiverTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst, Amber Coleman, (LPA) arrived to the Mountain View Cottages - VIII Facility to conduct a Case Management visit to address observed deficiencies not related to the complaint allegations. LPA met with Caregiver, Helen Nova, introduced self and stated purpose of the visit. LPA was invited inside and provided space to work.

On 4/5/2023, it was observed that the Administrator did not report the incident resulting in the disrepair of the facility's window.

Based on observations and interviews, a deficiency is being cited per Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted where this report was discussed and provided to Facility Representative.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2023
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


Document Has Been Signed on 04/14/2023 01:13 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: MOUNTAIN VIEW COTTAGES-VIII
FACILITY NUMBER: 366423658

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/14/2023
Section Cited

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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports ...Any incident which threatens the welfare, safety or health of any resident...
This requirement is not met as evidenced by
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Licensee will submit a statement of undertsnding of the reporting requirements by way of completing an LIC9098 form self certifying that the reporting requirement is understood and will be followed.
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Based on observations and interviews the Administrator did not report the incident resulting in the facility's disrepaired window, which poses a potential Health, Safety, or Personal Rights risk to persons in care.
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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: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2023
LIC809 (FAS) - (06/04)
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