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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197801605
Report Date: 09/30/2021
Date Signed: 09/30/2021 02:47:30 PM

Document Has Been Signed on 09/30/2021 02:47 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 VIEW CENTERFACILITY NUMBER:
197801605
ADMINISTRATOR:LAURA HERNANDEZFACILITY TYPE:
740
ADDRESS:715 WEST BASELINE ROADTELEPHONE:
(909) 626-6633
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 40CENSUS: 9DATE:
09/30/2021
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator, Trupti Mody TIME COMPLETED:
02:55 PM
NARRATIVE
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Licensing Program Analyst's (LPA's) Linda Almaraz and Elizabeth Irra conducted a subsequent visit for the purposes of completing the Annual/Required inspection. LPA's were greeted by staff member Daisy Fitter and former Administrator Laura Hernandez who assisted with the visit. Later during the visit at approximately 11:20AM, Administrator Trupti Mody arrived.

During today's annual continuation inspection, LPA's completed the Residents with Special Health Needs domain. The following was reviewed: Resident hospice files and staff training files. On 9/16/2021, LPA's did a walk-through of the facility, resident rooms and storage room. Resident #7 was missing re-appraisals for the year of 2018, and 2020. Resident #9 was missing re-appraisals for 2017 and 2018. Staff records did not have training records on administration of Oxygen for the year of 2020. LPA was provided with 2021 Oxygen training dates/record. Resident #4 and #9 had half bed rails and both had orders on file for full bed rails. During the following annual inspection visits (9/1/21, 9/16/21, and 9/30/21) LPA's observed the exterior gate and gate door locked at all times. The gate was locked with a chain and pad lock, and the gate door was locked on both sides by a key. Per interviews conducted, all caregivers have a key for the side gate door and would need to unlock if someone needs to exit through the door.

Deficiencies cited under California Code of Regulations Title 22.

An exit interview was conducted with the Administrator and provided a copy of this report. Appeal Rights were provided.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Linda M Almaraz
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2021
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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Document Has Been Signed on 09/30/2021 02:47 PM - It Cannot Be Edited


Created By: Linda M Almaraz On 09/30/2021 at 12:58 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: 09/30/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(l)(2)
Care of Persons with Dementia
(l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (2) The licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates.

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 by having the exterior gate locked with a chain and pad lock, and having the side gate door locked with on both sides with with a key. Based on interviews the gate door is locked at all time along with the gate and all caregivers have a key for the gate door. No fire clearance is on file with approval and licensing did not receive a request for the intent to lock all exterior gates and doors, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/01/2021
Plan of Correction
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Administrator will unlock exterior gate and door immediately. Will obtain approval from the Fire Department if they intent to lock the exterior gates and doors and will send their request to CCL prior to locking the gates and door.
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: 09/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2021


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 09/30/2021 02:47 PM - It Cannot Be Edited


Created By: Linda M Almaraz On 09/30/2021 at 12:58 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: 09/30/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

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. Resident #4 and #9 had half bed rails and both had orders on file for full bed rails, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/07/2021
Plan of Correction
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Administrator will obtain full bed rails for (R4) and (R7) and will send proof of correction to LPA by POC due date.
Type B
Section Cited
CCR
87618(b)(5)
Oxygen Administration - Gas and Liquid
(5) Ensuring that facility staff have knowledge of, and ability in the operation of the oxygen equipment.

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 by not having previous training records on file for staff in regards to Oxygen administration and handling. (R4) and (R7) records indicate they have been receiving Oxygen since 2020. The facility only had a sign-in sheet with the topic of Oxygen for the year of 2021 which poses potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/07/2021
Plan of Correction
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Administrator shalll have all staff trained on Administration of Oxygen and will maintain records of training on file. Administrator will provide training 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: 09/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2021


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/30/2021 02:47 PM - It Cannot Be Edited


Created By: Linda M Almaraz On 09/30/2021 at 12:58 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: 09/30/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(6)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals.

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. Resident #7 and #9 had missing reapprasails for previous years. (R7) had missing reappraisals for the year of 2018 and 2020. (R9) had missing reapprasails for the years of 2017 and 2018 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/07/2021
Plan of Correction
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Administrator will send a written plan of as to how they will comply with this regulation and will ensure all reapprasails are completed and filed in the residents file.
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: 09/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2021


LIC809 (FAS) - (06/04)
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