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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608323
Report Date: 09/10/2021
Date Signed: 09/10/2021 11:36:25 AM

Document Has Been Signed on 09/10/2021 11:36 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:MOUNTAIN VIEW TERRACE, LLCFACILITY NUMBER:
197608323
ADMINISTRATOR:LINDA MCINTOSHFACILITY TYPE:
740
ADDRESS:603 TOCINO DRIVETELEPHONE:
(626) 205-3211
CITY:DUARTESTATE: CAZIP CODE:
91010
CAPACITY: 6CENSUS: 5DATE:
09/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Linda McIntoshTIME COMPLETED:
11:45 AM
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On 9/10/2021 Licensing Program Analysts (LPAs) Nina Galarza and Nune Margaryan conducted an unannounced annual inspection visit at the Mountain View Terrace, LLC Facility. LPAs met with Administrator, Linda McIntosh and stated the purpose of the visit. The facility is licensed for six (6) non-ambulatory residents of age 60 and over, and (5) hospice care waivers. LPAs observed COVID informational and symptom postings outside and throughout the facility. There was hand sanitizer available for use as well.

LPAs toured the entire inside and outside facility grounds with Administrator. As part of the inspection, LPAs reviewed (5) resident medication records and inspected the inside facility and outside grounds. The two story house located in a residential neighborhood ( 2 nd floor staff designated), (first floor resident facility) consists of (4) resident bedrooms, (2) resident bathrooms, living room, family room, dining room, kitchen, laundry area, attached garage/storage, retractable patio awning, rectangular table with 4 patio chairs, barbecue area with refrigerator and surface counter, gated swimming pool with jacuzzi, constructed storage structure, and grass backyard. No weapons are stored in the premises. Kitchen was inspected and observed to be clean and operational. A 2- day supply perishable and 7-day supply of non-perishable foods are present in the facility. Emergency Water and food located in the garage. Staff are following modified diets as prescribed by doctors orders.

LPAs observed that all facility rooms are clean and in good repair. A comfortable temperature was observed, and the facility has central air and heating. LPAs observed the following during inspection of residents rooms: mattresses are in good condition, adequate lighting present, plenty of dresser/closet space is present, and all bed linens present. All bedrooms contain furniture, lighting fixtures and personal storage space as required, all beds have the required amount of linen and mattress covers, LPAs observed linen closet with bed sheets and towels. Extra toiletries supplies are located in the garage.
Report continued on form LIC 809-C.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nina Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 09/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2021
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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: MOUNTAIN VIEW TERRACE, LLC
FACILITY NUMBER: 197608323
VISIT DATE: 09/10/2021
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Bathroom fixtures are clean, in good repair, and working properly and contain the required nonskid mats and grab bars. LPA observed bathrooms were found to be within Title 22 regulation. LPAs tested water temperature in resident bathroom, water temperature was 115.4 degrees Fahrenheit at time of visit. Facility (1) Carbon Monoxide and (8) hard wired connected Smoke Detectors and second floor (staff) (1) Carbon Monoxide and (2) hard wired connected smoke detectors were tested and working properly. The facility (1) Fire Extinguisher was checked and found to be fully charged and accessible. All exit doors in the facility have alarm systems. All toxins and knifes are locked/secured and inaccessible to residents. Medications are centrally stored and in a locked storage cabinet. Facility first aid kit is fully stocked with manual was checked and in order. All Exits/ Walkways around the home were free of debris and hazards. Outside patio accessible to residents.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPAs did not observe deficiencies therefore no citations were issued at this time. An exit interview was conducted and a copy of the Facility Evaluation Report and appeal rights were provided to Linda McIntosh.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nina Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2021
LIC809 (FAS) - (06/04)
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