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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204372
Report Date: 09/21/2022
Date Signed: 09/21/2022 05:05:06 PM

Document Has Been Signed on 09/21/2022 05:05 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 COTTAGES -IIFACILITY NUMBER:
198204372
ADMINISTRATOR:TRUPTI MODYFACILITY TYPE:
740
ADDRESS:1000 PARK SPRING LANETELEPHONE:
(909) 860-6558
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY: 6CENSUS: 3DATE:
09/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:43 PM
MET WITH:Cherry Serame, staff
Primitivo Serame, Staff		TIME COMPLETED:
05:00 PM
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Licensing Program Analysts (LPAs) Tao and Ramirez conducted an unannounced annual inspection visit. LPAs met with staff, Cherry Serame and Primitivo Serame, who assisted with the visit. LPAs notified administrator upon arrival and spoke with Administrator, Trupti Mody at the end of the visit over the phone. Facility is licensed to serve six (6) non-ambulatory, developmentally disabled residents who are age 60 and above. Annual licensing fees are current.

During the visit, the infection control domain tool was used, a tour of the facility was conducted, food supply was reviewed, and medications were reviewed.



The facility is located in a residential neighborhood. LPAs toured the facilities physical plant, indoor and outdoor. The facility has five (5) resident bedrooms, two (2) staff bedrooms, three (3) full bathrooms, living room, kitchen, dining room, TV room and an indoor/covered outdoor activity area. All the rooms were furnished with appropriate furniture for residents’ comfort. The bathrooms were furnished with grab bars and nonskid surfaces. Common areas were observed for the ability to safely serve the needs of the residents. Hot water temperature was measured at 114.6 degrees Fahrenheit which was within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies was observed. No pools and bodies of water on the premises. Facility maintained a comfortable temperature for residents. Auditory alarm devices to monitor exits were operable. Interior and exterior space available to permit residents to wander freely and safely.

Sufficient supply of perishable and nonperishable foods is observed. Knives, tools, sharp items are inaccessible to residents. Smoke detectors and carbon monoxide detectors are operable. Fire extinguishers’ last service is 01/26/22 and are fully charged.

(-continued in LIC 809C-)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 COTTAGES -II
FACILITY NUMBER: 198204372
VISIT DATE: 09/21/2022
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Mandated documents and signages are posted in common areas. The outdoor activity area has a shaded patio with ample seating. Medication are centrally stored in a locked cabinet in the kitchen and inaccessible to residents. Resident records are stored in a locked cabinet and inaccessible to residents. Toxic substances are inaccessible to residents. Outdoor facility space are available for residents and leisure.

Deficiencies were observed and cited per California Code of Regulations, Title 22 in LIC 809 D.

An exit interview was conducted. This report was discussed with Staff, Cherry Serame. Staff’s signature on this form confirm receipt of these documents. A copy of LIC 809s report and appeal rights were provided.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/21/2022 05:05 PM - It Cannot Be Edited


Created By: Bonnie Tao On 09/21/2022 at 04:36 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 -II
FACILITY NUMBER: 198204372

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors

This requirement is not met as evidenced by:

The piece of cement at the backyard near the screen door is uprooted and the ground is uneven. It is a trip hazard .
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/05/2022
Plan of Correction
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Administrator agreed to level the cement and remove the uprooted tree near the uprooted cement piece 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.
SUPERVISOR'S NAME:Fernando Fierros
LICENSING EVALUATOR NAME:Bonnie Tao
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2022


LIC809 (FAS) - (06/04)
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