565800169-10-14-2022-29-AS-MARO-CK7QHY-20221014121156

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565800169
Report Date: 10/14/2022
Date Signed: 10/14/2022 12:12:51 PM

Document Has Been Signed on 10/14/2022 12:12 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	MOUNTAIN VIEW RESIDENTIAL CARE		FACILITY NUMBER:	565800169
ADMINISTRATOR:	EMMA SABIO		FACILITY TYPE:	740
ADDRESS:	290 DENA DRIVE		TELEPHONE:	(805) 498-2743
CITY:	NEWBURY PARK	STATE: CA	ZIP CODE:	91320
CAPACITY:	6	CENSUS: 3	DATE:	10/14/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Emma Sabio		TIME COMPLETED:	12:15 PM

NARRATIVE

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Licensing Program Analyst (LPA), Martha Arroyo arrived unannounced to conduct a Required 1-Year Annual Inspection with focus on Infection Control at 9:45 a.m. The last annual conducted at this location was on 8/19/2019. Upon arrival, LPA was greeted at the door by staff, Catharine. The Administrator, Emma Sabio arrived shortly after and the reason for the visit was explained. Entrance interview.

At 10:10 a.m., the LPA began the physical plant tour of the common areas, kitchen area, resident bedrooms, staff bedroom, bathroom, and outdoor area to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of seven (7) days perishable and two (2) days non-perishable food. The LPA observed all knives, sharps, medications, and facility files locked in the closet down the hallway inaccessible to residents in care.

BEDROOMS: The LPA observed the resident rooms, which were furnished appropriately with clean linens, furnishings, and sufficient lighting.

RESTROOMS: Resident restroom was clean and sanitary and in operating condition with grab bars and non-skid surfaces. Restroom is sufficiently stocked with hand liquid soap and paper towels. The appropriate hand-washing signs were observed throughout. At 10:17 am, the bathroom was measured for hot water and it measured at 140 degrees Fahrenheit. The administrator corrected the water temperature during time of visit.

…Report Continued on LIC 809C...

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022

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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MOUNTAIN VIEW RESIDENTIAL CARE	FACILITY NUMBER: 565800169
	VISIT DATE: 10/14/2022

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…Report Continued from LIC 809...

GARAGE AND GROUNDS: The garage is locked and detached from the house. There is an additional refrigerator in the garage. Cleaning supplies and chemicals are stored and inaccessible to residents. There is a covered patio area with patio furniture including a table and chairs for resident use. Facility has two (2) fence gates that self-latch with clear passageways for emergency exit use. No large bodies of water accessible to residents at the time of visit.

COMMON SPACES: The living and dining areas are clean and properly furnished with seating, a table, and television for resident use. The LPA observed two (2) residents in the dining room watching television at the time of visit.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. The LPA observed appropriate signage which promoted good hand hygiene, physical distancing, symptoms of COVID-19, and CDSS PINS. The facility has a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. All staff and residents are fully vaccinated and boosted. No identified staffing concerns.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).

Exit interview conducted. Appeal Rights Discussed. A copy of the report was provided via email.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/14/2022 12:12 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MOUNTAIN VIEW RESIDENTIAL CARE	FACILITY NUMBER: 565800169
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observation, the licensee did not comply with the section cited above as facility restroom faucets delivers hot water measured at 140 degrees Fahrenheit, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 10/14/2022
	Plan of Correction
1 2 3 4	The Administrator adjusted the thermostat during time of visit and has agreed to submit a hot water temperature log for five (5) days to show that the hot water is being maintained between temperatures 105- and 120-degrees Fahrenheit.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022

LIC809 (FAS) - (06/04)

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