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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197801605
Report Date: 10/28/2022
Date Signed: 10/28/2022 11:17:39 AM

Document Has Been Signed on 10/28/2022 11:17 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
GREATER LA AC/SC, 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: 31DATE:
10/28/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Laura HernandezTIME COMPLETED:
11:30 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 (LPAs) Kimberly Ramirez and Elizabeth Irra conducted a Case Management to obtain further information regarding a Special Incident involving R-1 and R-2 which occurred on 10/04/2022. LPAs met with Laura Hernandez and discussed the purpose of today's visit.

The Special Incident alleges that R-3 witnessed R-1 grabbed R-2 on the breast. R-1 has mild cognitive impairment and R-2 has Dementia. R-3 no longer resides at this facility.

During this visit, LPAs obtained a copy of the staff roster with contact information and a copy of the resident roster. At approximately 10 A.M., LPA reviewed resident files for Resident #1 through Resident #3 (R-1 through R-3) and obtained documentation. LPAs were unable to conduct interviews as there are (7) residents and (1) staff that tested COVID 19+ on 10/27/2022 (results were provided to Laura Hernandez today).

Exit interview conducted and a copy of this report was provided to Laura Hernandez.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2022
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