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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197801605
Report Date: 01/20/2023
Date Signed: 01/20/2023 10:37:59 AM

Document Has Been Signed on 01/20/2023 10:37 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: 33DATE:
01/20/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Laura HernandezTIME COMPLETED:
11:00 AM
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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 (5) residents currently receiving hospice care services.
  • Accusation/CDSS No.6221326301D was observed posted as required by Law. It was posted and readily accessible. Per Ms. Hernandez, new admissions have been notified of this accusation.
  • LPA conducted a tour of the premises and no health and safety concerns were observed.


Exit interview conducted, a copy of appeal rights and this report provided to Laura Hernandez.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/20/2023
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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