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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603080
Report Date: 01/27/2022
Date Signed: 01/27/2022 11:23:32 PM

Document Has Been Signed on 01/27/2022 11:23 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:MOUNTAIN VALLEY VIEWFACILITY NUMBER:
374603080
ADMINISTRATOR:WINTERS, KEVIN & KARIFACILITY TYPE:
740
ADDRESS:16916 DEER HILL ESTATESTELEPHONE:
(858) 748-5656
CITY:LAKESIDESTATE: CAZIP CODE:
92040
CAPACITY: 6CENSUS: 4DATE:
01/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:21 AM
MET WITH:Caregivers, Robert Encomienda and Elvira ManzanoTIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Debbie Correia conducted an annual required licensing inspection. LPA Correia met with Caregivers Robert Encomienda and Elvira Manzano, identified herself, was granted entrance into the facility, and explained the purpose of the visit.

LPA Correia, accompanied by Caregiver Manzano, conducted an overall tour of the facility. The inspection included, but was not limited to, verifying compliance with statutes, regulations and other written requirements that are most relevant to protecting the health of residents in care and staff, including in the area of infection control practices.

LPA reviewed the facility’s Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Plan Report (LIC 808) during the inspection, including but not limited to the following sections: Clients in Care, Staff, Visitors, Facilities without COVID-19. The facility has Plans for Infection Control, and will implement Physical Distancing as needed. LPA assessed the strategies that the facility is employing for the prevention, containment and mitigation of COVID-19, implementation of infection control guidance, ability to quarantine or isolate if necessary and essential health and safety.

LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff, clients and visitors; a sign-in policy enacted for all visitors; signs posted throughout the facility to promote hand hygiene, cough/sneeze etiquette and physical distancing; face coverings worn by staff and as much as possible, residents; hand sanitizer/hand washing stations readily available; emergency agencies’ contact information posted in a location visible to staff and residents; and an adequate supply of PPE.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2022
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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: MOUNTAIN VALLEY VIEW
FACILITY NUMBER: 374603080
VISIT DATE: 01/27/2022
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No deficiencies were observed during today's visit. An exit interview was conducted with Caregiver Manzano, and a copy of this report along with the Licensee Rights (LIC 9058 FAS 01/16) will also be provided via email to the Caregiver Manzano and Licensee Winters at the conclusion of the visit. An electronic reply response confirms receipt of these documents.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022
LIC809 (FAS) - (06/04)
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