<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197801605
Report Date: 04/28/2022
Date Signed: 04/28/2022 10:16:54 AM

Document Has Been Signed on 04/28/2022 10:16 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: 20DATE:
04/28/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Elvira Cortez (Activity Director)TIME COMPLETED:
10:30 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPA) Elizabeth Irra conducted an unannounced Plan Of Correction (POC) visit to follow up on the Plan of Correction citations issued during the 04/14/2022 case management visit. The purpose of this visit was explained to Elvira Cortez. Laura Hernandez (Assistant Administrator) arrived at approximately 10:05 A.M. and LPA re-explained the purpose of this visit.

On 04/14/2022 the facility was cited for: California Health and Safety Code: 1569.38(b)(1) Posting of licensing reports; disclosure to new residents. (b) A licensed residential care facility for the elderly shall provide written notice to a resident, the resident’s responsible party, if any, and the local long-term care ombudsman, within 10 days from the occurrence of either of the following events: (1)The department commences proceedings to suspend or revoke the license of the facility pursuant to Section 1569.50. Licensee failed to disclose a written notice to a resident, the resident’s responsible party and the local long-term ombudsman within 10 days from the occurrence.

As of today, DEFICIENCY IS NOT CLEARED. Civil Penalties are being issued for period 04/19/2022-04/28/2022. Total of 10 days, at $100.00 per day. The amount noted on Civil Penalty (LIC 421FC) is $ 1,000.00. A civil penalty of $100 per violation per day shall be assessed until the violation is corrected.

Deficiencies are cited per Health & Safety Code Sections 1569.38.



LPA explained the citations, civil penalty assessment, and appeal rights.

Exit interview conducted, a copy of appeal rights, civil penalties and this report provided to Laura Hernandez
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1