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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204371
Report Date: 02/17/2026
Date Signed: 02/17/2026 05:43:27 PM

Document Has Been Signed on 02/17/2026 05:43 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:MOUNTAIN VIEW COTTAGES - VFACILITY NUMBER:
198204371
ADMINISTRATOR/
DIRECTOR:		TRUPTI MODYFACILITY TYPE:
740
ADDRESS:1738 MAPLE HILL ROADTELEPHONE:
(909) 860-7534
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY: 4CENSUS: 4DATE:
02/17/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Eva Nainggolan - Direct Care Staff/DSP II
Paran Mody, Administrative Assistant		TIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required-1 year visit. LPA was met by Eva Nainggolan, Direct Care Staff/DSP II and explained the purpose of the visit. The Administrator, Trupti Mody was called on the phone. The facility is licensed to serve (4) non-ambulatory residents ages 60 and above, of which (1) may be bedridden. Bedroom #5 is approved for the bedridden resident. Facility cares for dementia residents and has a hospice waiver approved for (4) residents. The facility is vendorized by the San Gabriel/Pomona Regional Center. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were maintained. Bathroom has hygiene items such as hand soap and toilet paper. Staff are trained in the proper use of required PPEs.

Operational Requirements: A fire clearance is in place. Facility has signal systems in exit points but some are inoperable. Liability of insurance is not readily available for review in the facility. Surety bond is valid in the amount of $3000 and expires on 09/29/2026. There are (2) fire extinguishers in the facility which was last serviced on 02/10/2026.

Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood that consists of (4) resident bedrooms, (2) staff bedrooms, (2.5) bathrooms, living room with a fireplace, activity room, kitchen, dining area, backyard with a covered patio and equipped with outdoor furniture and attached garage with a laundry area. The interior and exterior physical plant was inspected. Resident bedrooms were toured. Each bedroom has a smoke detector, linen, light, chair and sufficient closet space. There are video surveillance in the common areas of the facility. Facility has interconnected smoke detectors and carbon monoxide detectors at the home. Knives, cleaning solutions, and disinfectants are locked. Sufficient food supplies are observed. The facility has a dementia care plan to accept or retain residents with dementia. There are no firearms or weapons stored at the facility. Water temperature reading measured at 107 deg F in bathroom #1 and 109.2 deg F in bathroom #2 which are within the required 105 - 120 degrees Fahrenheit. *****REPORT CONTINUED ON LIC809-C****

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/17/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: MOUNTAIN VIEW COTTAGES - V
FACILITY NUMBER: 198204371
VISIT DATE: 02/17/2026
NARRATIVE
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Staffing: A total of six (6) staff members including the Administrator provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have the required training and associated to the facility.
Personnel Records/Staff Training: Administrator's proof of health clearance, fingerprint clearance, vaccinations and 1st Aid/CPR training are current. Administrator's certificate is valid and expires on 05/31/2026.
Resident Rights-Information: Rights of individuals with disabilities are posted. Facility provides internet services to all residents and have access to the facility phone.
Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities.
Food Service: The kitchen was inspected and has sufficient supply of 2-day perishable & 7 day non-perishable food. LPA observed that food containers inside the refrigerator were not labeled.
Incidental Medical Services: Medications reviewed for all (4) residents. Residents have Restricted Health Care Plan and Needs and Services Plan on file. Currently, (1) resident is bedridden and under hospice care. Residents medication are centrally stored in a locked cabinet in the kitchen area.
Resident Records-Incident Reports: All (4) resident files were reviewed containing admission agreements, Physician's Report, Medical/Functional assessments, Needs and Services Plans, TB clearance, Personal rights, Medical Consent, Medication Records, Restricted Health Care Plans and Hospice Notes/Records were reviewed. During medication review, LPA observed that the bedtime medications for (1) resident was administered on the evening of 02/16/2026, however, the staff failed to sign/initial the Medication Administration Record (MAR).
Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan. The facility conducts emergency drill on a quarterly basis. Last fire drill was conducted on 07/18/2025.
Residents with SHN: One (1) resident receive hospice care. Appraisals were observed in resident files.


Deficiency cited and Technical Advisories were issued. Exit interview and a copy of this report along with the appeal rights were provided to Paran Mody, Administrative Assistant.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/17/2026 05:43 PM - It Cannot Be Edited


Created By: Bennette Pena On 02/17/2026 at 03:32 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 COTTAGES - V
FACILITY NUMBER: 198204371

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/17/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the Administrator did not comply with the section cited above in that based on observation, the bedtime medications for (1) resident was administered on the evening of 02/16/2026, however, the staff failed to sign/initial the Medication Administration Record (MAR), which poses/posed an immediatel health, safety or personal rights risk to residents in care.
POC Due Date: 02/18/2026
Plan of Correction
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Administrator shall provide in-service training to all staff on how to properly document the Medication Administration Record (MAR), as well as develop a policy requiring that (2) people verify medication records. Administrator to send a copy of the training log, along with the topics covered, and a sign-in sheet of staff who participated to CCL/LPA by POC due date.
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.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Bennette Pena
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2026


LIC809 (FAS) - (06/04)
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