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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197801605
Report Date: 06/08/2022
Date Signed: 06/08/2022 04:12:51 PM

Document Has Been Signed on 06/08/2022 04:12 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: 20DATE:
06/08/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Laura Hernandez TIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced Case Management visit to check the health and safety of residents, and to ensure Accusation/CDSS No. 6221326301D was posted as required by Law. LPA explained the purpose of the visit to Laura Hernandez.
  • There are (6) residents currently receiving hospice care services (same total as previous visit conducted 05/26/2022).
  • Accusation/CDSS No.6221326301D was observed posted as required by Law. It was posted and readily accessible.
  • LPA conducted a tour of the premises and no health and safety concerns were observed.
  • LPA informed Laura Hernandez that all new residents being admitted into this facility be informed of the accusation noted above.

Exit interview conducted, a copy of appeal rights and this report provided to Laura Hernandez. Note: LPA was experiencing technical difficulties during this visit. This report will be emailed to Ms. Hernandez at the email.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/08/2022
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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