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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204372
Report Date: 03/13/2023
Date Signed: 03/13/2023 03:32:52 PM

Document Has Been Signed on 03/13/2023 03:32 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
GREATER LA AC/SC, 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:
03/13/2023
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Trupti Mody, AdministratorTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted a case management visit to change the capacity from 6 to 4. LPA met with Administrator Trupti Mody. The fire inspection conducted on 10/26/22 is cleared for a capacity of (4) developmentally disabled residents, ages 60 and above, of which (3) may be non-ambulatory and (1) bedridden. The bedridden resident is approved for bedroom #1 only. The current 3 residents residing at the facility were placed by the San Gabriel/Pomona Regional Center.

LPA toured the facility and observed the following:
* There is a total of 7 bedrooms and 3 bathrooms at the facility. Per the Administrator, the residents will only be utilizing bedrooms #1, #2, and #3, which are located to the right side of the home. Bedroom #1 has a private bathroom. All 3 resident bedrooms have exit doors with auditory alarm device installed. Bedroom #4 is occupied by the live-in staff.
* Bedrooms #5, #6, and #7 located to the left side of the home will not be used as resident bedrooms. Administrator will use those as staff rooms.
* Food supplies are sufficient for 3 residents.
* There are sufficient plates and utensils for the capacity of 4.

An exit interview was held. A copy of this report was provided to the administrator.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 03/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2023
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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