Community Care Licensing

Document Has Been Signed on 09/16/2021 03:46 PM - It Cannot Be Edited

FACILITY NAME:	MOUNTAIN VIEW CENTER		FACILITY NUMBER:	197801605
ADMINISTRATOR:	LAURA HERNANDEZ		FACILITY TYPE:	740
ADDRESS:	715 WEST BASELINE ROAD		TELEPHONE:	(909) 626-6633
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY: 40		CENSUS: 9	DATE:	09/16/2021
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Licensee, Smita Sanghvi		TIME COMPLETED:	04:00 PM

SUPERVISORS NAME: Christine Yee LICENSING EVALUATOR NAME: Linda M Almaraz LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2021

Link to Parent Document Below:

FACILITY NAME: MOUNTAIN VIEW CENTER	FACILITY NUMBER: 197801605
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/16/2021

Type B

Section Cited

HSC

1569.695(a)(4)(B)

This requirement is not met as evidenced by: Upon reviewing the Emergency Disaster Plan for Residential Care For Residential Care Facilities for the Elderly (LIC 610E) it was incomplete with missing components and had an incorrect number for CCLD.
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/23/2021
	Plan of Correction
1 2 3 4	Administrator will review the LIC 610E and ensure all emergency numbers are correct and missing components are completed along with verifying responsible members are current employees of the facility. Administrator will send updated LIC 610E to LPA by POC due date.

Type B

Section Cited

HSC

15969.695(a)(7)(F)

This requirement is not met as evidenced by: Upon reviewing Emergency and Disaster Plan for Rseidential Care Facilities for the Elderly (LIC 610E) the facility did not have a plan in place for residents on oxygen in the event of disaster/emergency. LPA's verified Oxygen tanks which did not require electricity with the Med-Tech and Administrator. The facility only had (7) full tanks. Per Med-Tech and Administrator the tanks last anywhere from 6-8hrs. The facility has a total of (4) residents on Oxygen which would not be sufficient for 72 hours.
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/23/2021
	Plan of Correction
1 2 3 4	The Administrator shall come up with a plan to ensure all residents who are on Oxygen, have available the adequate amount of oxygen for each resident for a period of 72hrs in the event of an emergency and will send the plan to LPA by the POC due date.

SUPERVISOR'S NAME: Christine Yee LICENSING EVALUATOR NAME: Linda M Almaraz LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2021

Link to Parent Document Below:

FACILITY NAME: MOUNTAIN VIEW CENTER	FACILITY NUMBER: 197801605
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/16/2021

Type B

Section Cited

HSC

15969.695(b)

This requirement is not met as evidenced by: Per Administrator and staff member only new hires are provided training and they do not provide the training annually. Administrator could not provide training material.
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/23/2021
	Plan of Correction
1 2 3 4	The Administrator shall ensure all staff receive training annually. Administrator will provide training curriculume to the LPA by POC due date and proof of training conducted with all staff.

Type B

Section Cited

HSC

15969.695(f)(2)(B)

This requirement is not met as evidenced by: The facility did not have keys available or a designated location for the keys of an emergency vehicle used to transport residents in the event of an evacuation.
	Deficient Practice Statement
1 2 3 4	Based on observation, interviews and record review, the licensee did not comply with the section cited above which poses posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/23/2021
	Plan of Correction
1 2 3 4	The Administrator shall have designate a vehicle and implement a location for the keys at the facility. Administrator will incorporate the information onto the plan and send the updated LIC610E to LPA by POC due date

SUPERVISOR'S NAME: Christine Yee LICENSING EVALUATOR NAME: Linda M Almaraz LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2021

Link to Parent Document Below:

FACILITY NAME: MOUNTAIN VIEW CENTER	FACILITY NUMBER: 197801605
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/16/2021

Type B

Section Cited

HSC

15969.695(a)(3)

This requirement is not met as evidenced by: The facility did not have an emerhency route listed on their LIC 610E. Per Administrator, the previous Administrator was working on the form and resigned without completing it.
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/23/2021
	Plan of Correction
1 2 3 4	Administrator will create an emergency route and update their LIC 610E. Administrator will send the updated LIC 610E to the LPA by POC due date

Section Cited

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

SUPERVISOR'S NAME: Christine Yee LICENSING EVALUATOR NAME: Linda M Almaraz LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2021