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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608323
Report Date: 09/09/2025
Date Signed: 09/09/2025 04:00:36 PM

Document Has Been Signed on 09/09/2025 04:00 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:MOUNTAIN VIEW TERRACE, LLCFACILITY NUMBER:
197608323
ADMINISTRATOR/
DIRECTOR:		LINDA MCINTOSHFACILITY TYPE:
740
ADDRESS:603 TOCINO DRIVETELEPHONE:
(626) 205-3211
CITY:DUARTESTATE: CAZIP CODE:
91010
CAPACITY: 6CENSUS: 5DATE:
09/09/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Chileshe Shikabenga, CaregiverTIME VISIT/
INSPECTION COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced Required-1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by Chile Shikabenga, Care Staff and explained the purpose of the visit. Administrator Linda McIntosh and House Manager, Brittney McIntosh arrived and assisted LPA with the inspection. The facility is licensed to care for six (6) elderly residents ages 60 and above, approved for (6) non-ambulatory residents and hospice waiver for (5) residents.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were maintained. The facility has an Infection Control Plan in place. Bathroom has hygiene items such as hand soap and toilet paper. Paper towels are only provided in the bathroom. Facility uses cloth/reusable towels in the kitchen.

Operational Requirements: LPA reviewed the Infection Control Plan in place. A fire clearance is in place. Last Fire Drill was conducted on 09/02/2025 and training conducted on a monthly basis. The administrator has valid liability insurance in place. Facility does not handle cash resources for the residents. The facility has working signal systems in exit points, which LPA along with the Administrator tested during the visit.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: MOUNTAIN VIEW TERRACE, LLC
FACILITY NUMBER: 197608323
VISIT DATE: 09/09/2025
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Physical Plant/Environment Safety: The facility is a 2-story home located in a residential neighborhood, 1st floor consists of (4) resident bedrooms, (2) bathrooms, living room with screened fireplace, den/tv area with screened fireplace, kitchen, dining area, laundry area, detached garage, backyard with gated swimming pool, small storage building, shed, shaded patio area. The 2nd floor consists of an office area, staff sleeping quarter with curtains as a divider for privacy and (1) bathroom. Currently, there are five (5) residents living in the facility. The interior and exterior physical plant was inspected. Resident bedrooms were toured. Each bedroom has a smoke detector, bed with 1/2 and full bed rails, linen, dresser, light, chair and sufficient closet space. Beds and furnishings were all in good working condition. Extra linens and towels are in the hallway closet. Exit doors are free of any obstruction and there is a gated swimming pool in the backyard. Backyard was inspected and has a shaded area and sitting area. The fireplace is closed and inaccessible to clients. The laundry area is in the hallway. There is one (1) fire extinguisher that is fully charged in the kitchen and was last inspected on September 2025. Carbon monoxide was tested and operable. There are no firearms or weapons stored at the facility. Water temperature readings were measured at 114.6 deg in bathroom #1, 113.7 deg F in bathroom #2 which are within the 105 degrees F and 120 degrees F Title 22 regulation.

Staffing: A total of seven (7) staff members including the Administrator provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and are associated to the facility.

Personnel Records/Training: LPA reviewed four (4) staff files that include personnel records, health clearance, TB test results, criminal background fingerprint clearance, 1st Aid/CPR training, Employee Rights, and staff training. The administrator certificate is valid and will expire on 07/26/2027.

Resident Rights-Information: Resident personal rights, complaint hotline information and visitors’ policy posters are posted. Per Administrator, facility provides internet services to all residents and have access to the facility phone.

Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. Activities supply observed.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2025
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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: MOUNTAIN VIEW TERRACE, LLC
FACILITY NUMBER: 197608323
VISIT DATE: 09/09/2025
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Food Service: Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. There are sufficient food supplies of 2-day perishable and 7-day non-perishable items. The food is properly stored in the refrigerator. Pesticides and cleaning supplies are kept away from the food preparation areas. Plates, cups and utensils are kept clean and stored properly. Per administrator, there are no residents that have a modified diet.

Incident Medical and Dental: Medications were reviewed for five (5) residents to confirm medication is given as prescribed and is documented properly. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. Medications are bubbled packed and stored in a locked medicine cart.

Resident Records-Incident Reports: LPA reviewed five (5) resident files. Resident files are maintained at the facility. Admission Agreement, I.D. and Emergency Information (Face sheet), Physician's Report (including TB and Ambulatory Status), Physician's order for bed rails, Admission Agreement, Appraisal and Needs Services plan, Pre-Admission Appraisal, Resident Personal Rights, and Resident Personal Property observed.

Disaster Preparedness: Emergency and Disaster Plan LIC 610E was reviewed. Evacuation chairs are in place. The facility has a First Aid Kit with all required items.

Residents with Special Health Needs: Per Administrator, there are four (4) residents receive hospice services and no residents receives home health services. Half bed rails for mobility assistance were observed in some resident rooms and LPA reviewed resident files with half bed rail orders. No residents have prohibited health conditions.

Per the California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during today’s visit. Exit interview was held and a copy of the report was provided to Administrator Linda McInto.sh

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2025
LIC809 (FAS) - (06/04)
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