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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366423658
Report Date: 06/16/2023
Date Signed: 06/16/2023 11:44:15 AM


Document Has Been Signed on 06/16/2023 11:44 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
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:
06/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Staff- Novita NovitaTIME COMPLETED:
11:55 AM
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 Licensing Program Analyst (LPA) Victoria Chitgian made an unannounced visit to conduct a Required Annual inspection. LPA met with House Manager Jasbindar Singh. This Residential care facility for the elderly is licensed for six (6) non-ambulatory and has a hospice waiver for two (2).
LPA observed that there are currently five (5) residents admitted to the facility. There are no pools, bodies or water, firearms or ammunition. LPA observed the facility is kept at a comfortable temperature of 74 degrees F. Hot water was measured in resident’s bathrooms at 111 degrees Fahrenheit. LPA observed grab bars where appropriate and non-skid mats or strips in showers and tubs. LPA observed a sufficient supply of towels, linens and personal hygiene items. Cleaning supplies were observed to be locked and inaccessible to the residents. The facility’s smoke detectors and carbon monoxide detectors were tested and are in working condition. LPA observed the fire extinguisher to be recently serviced and completely charged.
LPA observed the kitchen to be clean and free of odor and all food is stored and prepared in a healthful manner. All frozen and refrigerated food is sealed correctly and protected against contamination. LPA observed an appropriate food supply of 7-day non-perishable. The back yard is completely enclosed and revealed no immediate hazards. LPA observed where resident’s medications would be centrally located and secured and inaccessible to residents. Appropriate number of staff are present in the facility during operating hours and during the evening/sleeping hours.
LPA reviewed facility files and resident files for admission agreements, physician reports and written records of care. All files were organized and complete. LPA reviewed the posted signs and policies, including the Emergency and Disaster plan (LIC 610E). LPA observed the completed date to be from 2021. Technical violation issued. LPA reviewed Administrators file and observed a lack of training hours in Laws and Regulations. Technical violation issued. Per record review, last emergency drill was conducted on 5/31/2023.

No deficiencies cited per Title 22, Division 6 of the California Code of Regulations at this time. Two(2) technical violations issued. An exit interview was conducted where this report was discussed and provided to House Manager Jasbindar Singh at the end of the visit.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Victoria ChitgianTELEPHONE: (951) 248-0306
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2023
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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