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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197801605
Report Date: 09/01/2021
Date Signed: 09/03/2021 10:17:13 AM

Document Has Been Signed on 09/03/2021 10:17 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 CENTERFACILITY NUMBER:
197801605
ADMINISTRATOR:LAURA HERNANDEZFACILITY TYPE:
740
ADDRESS:715 WEST BASELINE ROADTELEPHONE:
(909) 626-6633
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 40CENSUS: 10DATE:
09/01/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Licensee, Smita SanghviTIME COMPLETED:
06:00 PM
NARRATIVE
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Licensing Program Analyst's (LPA's) Linda Almaraz, Christine Wong, Tony Vasallo and Nina Galarza conducted a visit for the Annual/Required inspection. LPA's met with Licensee, Smita Sanghvi and former Administrator Trupti Mody. Staff member Daisy Fitter and Med-tech Elvira Cortez assisted with the facility walk-through.

A tour of the facility includes a single-story building with administrative offices, employees lounge, conference room, and commercial-size kitchen. The second single-story building includes a, medication room, residents rooms, bathrooms, and indoor/outdoor areas. All residents bedrooms have the required furniture for privacy, comfort, and safety. Bathrooms are clean and operational. The following bathrooms hot water temperature was not within the required range of 105-120 degrees F; the first bathroom of the left wing of the building was tested at 125.7 degrees F, bathroom in room #9 which was at 123.8 degrees F, and bathroom in between rooms 4 and 5 was at 121.8 degrees F. Bathroom in room #20, on the right wing of the building was at 102.9 along with bathroom between rooms 18 and 19 which was at 80.1. Bathroom in room #18 on the right side wing has a peeling boarder on the wall of the bathroom floor near the toilet. Bathroom #4 was missing non-skid mat. Both linen closets on the left wing had what appeared to be rat droppings. The commercial-size kitchen was observed for the ability to prepare and serve food. LPA's observed an appropriate food supply of two (2) days of perishables and seven (7) days of non-perishables. There is an additional storage area of food supply for emergency preparedness. All storage areas for chemical compounds, cleaning solutions, toxins, knives or hazardous items are located in the front building.

Facility’s central air & heating system is operational. LPA's observed the carbon monoxide device(s) which were tested and appear to be operational. A pull switch, fire alarm sounding device was observed in the hallway/main entrance in second building. Fire extinguishers are fully charged with posted sign. First-aid kit is fully stocked. Facility's call system was not operational. According to Staff #2 the system has not worked for some weeks and they provided small bells to residents until they repair the call system. (Cont LIC 809-C)

SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Linda M Almaraz
LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2021
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 CENTER
FACILITY NUMBER: 197801605
VISIT DATE: 09/01/2021
NARRATIVE
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Landscape and the passageways are free of obstruction. The outdoor activity area is free of visible hazards, debris, and the containers have covered lids. There are no security bars nor weapons or bodies of water (pool/spa) on the premises.

LPA's reviewed the facility’s profile, personnel summary report, staff roster & work schedules, personnel files & training records, register of residents, residents’ administrative files & medical records, medications (for proper storage, documentation, and system implementation). LPA's observed the following; Staff #4's personnel file did not have a health screening form. Resident #9's medication (Aquaphor ointment, grratorpium/Albueerol, and PRN Lactulose 10mg/15 solution) was not present at the facility. Resident #6's medication (PRN melatonin 5mg) was not present at the facility. Resident #4's medication (Calmoseptine ointment) was not labeled with the residents name. Resident #6's medication (D-Mannose with Cranberry Dandelion Extract) was not labeled with the residents name.

LPA also observed the required mandated documents/poster were not posted in a prominent place, such as Personal Rights and CCL "Let us no" complaint poster.

The following deficiencies were observed to be in violation under California Code of Regulation Title 22. Refer to LIC 809D.

Due to time constrains the following domains were not completed: Disaster Preparedness and Residents with Special Health Needs and will be reviewed at a later time. Note: Any deficiencies observed during the visit that are not cited today will be cited on the next visit.

An exit interview was conducted telephonically due to networking issues at the facility. LPA Almaraz contacted former Administrator Trupti Mody later in the afternoon and also provided a copy of the Facility Evaluation Report via email for a signature. Appeals Rights provided.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Linda M Almaraz
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021
LIC809 (FAS) - (06/04)
Page: 7 of 8
Document Has Been Signed on 09/03/2021 10:17 AM - It Cannot Be Edited


Created By: Linda M Almaraz On 09/01/2021 at 04:30 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 VIEW CENTER
FACILITY NUMBER: 197801605

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2021

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, the licensee did not comply with the section cited above in 5 bathrooms not being withing the required range per Title 22 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/02/2021
Plan of Correction
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Licensee shall adjust water temperatures for the whole facility to be within regulation limits of 105-120 degree F immediately. Licensee will monitor for 7 days straight and will document the readings. Licensee will send proof of correction by submitting the log to LPA upon completeing the 7 day log.
Type A
Section Cited
CCR
87465(h)(4)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 2 out of 10 residents did not have their medication labeled with their name which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/02/2021
Plan of Correction
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Licensee will label residents #4 and #6's medication and will ensure all medication is labeled with the appropiate residents name/information. Licensee will send picture of correction by POC due date
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:Linda M Almaraz
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2021


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Document Has Been Signed on 09/03/2021 10:17 AM - It Cannot Be Edited


Created By: Linda M Almaraz On 09/01/2021 at 04:30 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 VIEW CENTER
FACILITY NUMBER: 197801605

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks.  Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure.  A report shall be made of each screening, signed by the examining physician.  The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents.  A signed statement shall be obtained from each volunteer affirming that he/she is in good health.  Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 4 staff records reviewed did not have a health screening form which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/10/2021
Plan of Correction
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Licensee will send LPA a copy of Staff #4's health screening form and will ensure all staff files have a copy of the form in their file.

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:Linda M Almaraz
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2021


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 09/03/2021 10:17 AM - It Cannot Be Edited


Created By: Linda M Almaraz On 09/01/2021 at 04:30 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 VIEW CENTER
FACILITY NUMBER: 197801605

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Both linen closets on the left wing had what appeared to be rat droppings and bathroom in room #18 on the right side wing has a peeling boarder on the wall of the bathroom floor near the toilet which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/10/2021
Plan of Correction
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Licensee willl contact a exterminator to come and service the facility and will have the bathroom border/wall repaired. Licensee will send LPA a picture of the bathroom border/wall and a copy of the exterminator report.
Type B
Section Cited
CCR
87303(e)(5)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Bathroom in room #4 was missing a non-skid mat which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/03/2021
Plan of Correction
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Licensee will ensure all bathrooms maintain a non-skid mat/skid. Licensee will send a picture of correction to LPA by POC due date.
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:Linda M Almaraz
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2021


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 09/03/2021 10:17 AM - It Cannot Be Edited


Created By: Linda M Almaraz On 09/01/2021 at 04:30 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 VIEW CENTER
FACILITY NUMBER: 197801605

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(i)(1)(A)
Maintenance and Operation
(i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (A) Operate from each resident's living unit.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not having an operable call system that alerts staff which room needs assistance which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/15/2021
Plan of Correction
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Licensee will have the call system service and ensure all call systems in each room are working. Licensee shall send receipt of service by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Linda M Almaraz
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2021


LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 09/03/2021 10:17 AM - It Cannot Be Edited


Created By: Linda M Almaraz On 09/01/2021 at 04:30 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 VIEW CENTER
FACILITY NUMBER: 197801605

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(c)(2)(A)
Personal Rights of Residents
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Personal Rights and Community Care Licensing (CCL) "Let us no" (PUB 475) complaint poster was not present at the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/02/2021
Plan of Correction
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Licensee shall post both, Personal Rights and CCL complaint poster. Licensee shall send pictures as proof of correction by POC due date. During the visit, staff posted complaint poster.

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:Linda M Almaraz
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2021


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 09/03/2021 10:17 AM - It Cannot Be Edited


Created By: Linda M Almaraz On 09/01/2021 at 08:07 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 VIEW CENTER
FACILITY NUMBER: 197801605

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(1)
(a) A plan for incidental medical and dental care shall be developed by wach facility. The plan shall eencourage routine medical and dental care and provide for assistance in obtaining such care, by complaince with the following: (1) The licensee shall arranging, for medical and dental care appropriate to the conditions and needs of residents


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in 2 out of 10 residents medications were not present at the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/02/2021
Plan of Correction
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4
Licensee shall obtain missing medication for both residents, Resident #6 and #9, and will send a picture of medication by POC due date to LPA.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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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:Christine Yee
LICENSING EVALUATOR NAME:Linda M Almaraz
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2021


LIC809 (FAS) - (06/04)
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