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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609508
Report Date: 02/08/2022
Date Signed: 02/08/2022 05:14:47 PM

Document Has Been Signed on 02/08/2022 05:14 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:MOUNTAIN VILLAFACILITY NUMBER:
197609508
ADMINISTRATOR:NARINE SARYANFACILITY TYPE:
740
ADDRESS:1845 W. MOUNTAIN STREETTELEPHONE:
(818) 945-5644
CITY:GLENDALESTATE: CAZIP CODE:
91201
CAPACITY: 6CENSUS: 4DATE:
02/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:43 PM
MET WITH:Narine Saroyan, AdministratorTIME COMPLETED:
05:17 PM
NARRATIVE
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On 02/08/2022 Licensing Program Analyst (LPA) Alberto Lopez, conducted a required annual inspection. LPA was greeted by Administrator Narine Saroyan. LPA Discussed the purpose of the meeting. Currently, the home has (3) ambulatory clients and (1) non-ambulatory client. Facility is a single-story residence located in a residential neighborhood. The facility consists of five (5) bedrooms, (3) of the bedrooms are resident rooms. Living room, Dining room, kitchen, and (4) restrooms (2) of them are for residents. There is a large, covered patio area with swimming pool that is situated behind a secured fence. The resident’s bedrooms are spacious and will easily accommodate residents' furnishings. The back-patio area has furniture for the resident’s leisure. The last fire and earthquake drill were conducted on 01/04/2021. Administrator Certificate has expired in 2020.

The following were observed/inspected:



· COVID-19 signs are posted at the entrance. Visitors are screened in the main entrance and a log is kept.
· Infection control signs and other COVID-19 signs are posted throughout the facility in the bathrooms, kitchen, and hallway to promote handwashing, cough/sneeze etiquette, and physical distancing.
· Facility has one designated isolation room.
· 5 client rooms, common areas, bathrooms, and outdoor physical plant was inspected.
· Nine client rooms were not equipped with alcohol-based hand sanitizer.
· Four (4) centrally stored client medication records were reviewed.
· Staff responsible for direct care and supervision were observed wearing masks.
· Clients were not observed wearing masks but adhering to public health social distance guidelines.
· Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed.
· A posted Emergency Disaster Plan was observed posted.
· PPE's were observed.
· Staff and resident files were not reviewed during today's visit.
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Deficiencies cited per Title 22 Health and safety code, please see 809D
Exit interview was conducted with Administrator Narine Saroyan. A copy of the report was provided.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 02/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/08/2022
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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Document Has Been Signed on 02/08/2022 05:14 PM - It Cannot Be Edited


Created By: Alberto Lopez On 02/08/2022 at 04:38 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MOUNTAIN VILLA
FACILITY NUMBER: 197609508

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/08/2022

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
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Based on observation, LPA Lopez and Administrator observed water temperture at 125.4 Degress F in the bathroom next to the kitchen. The licensee did not comply with the section cited above in 1 of 1 count which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/09/2022
Plan of Correction
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Administrator will take water temperture and send photos of the measurements that fall between the range of 105 - 120 degrees F
Type A
Section Cited
CCR
87412(a)(13)(B)1
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: (B) Documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e). 1. For Certified Administrators, a copy their current and valid Administrative Certification meets this requirement.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interviews , the licensee did not comply with the section cited above in 2 counts out of 2 persons which poses an immediate health, safety or personal rights risk to persons in care. Stella Balasaryan and Shushanna Artin are not associated to facility.
POC Due Date: 02/09/2022
Plan of Correction
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 All staff shall be properly associated to facility. Criminal Record Transfer Request-and Photo I.D. must be sent for all previous cleared individual staff and a copy kept on file for validation that request was sent. Also, Current Administrator certificate or application for it shall be to LPA by POC.
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:Christine Yee
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2022


LIC809 (FAS) - (06/04)
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