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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204376
Report Date: 11/26/2024
Date Signed: 11/26/2024 01:22:30 PM

Document Has Been Signed on 11/26/2024 01:22 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 - IVFACILITY NUMBER:
198204376
ADMINISTRATOR/
DIRECTOR:
TRUPTI MODYFACILITY TYPE:
740
ADDRESS:21027 WEST COVINA BLVD.TELEPHONE:
(626) 966-4842
CITY:COVINASTATE: CAZIP CODE:
91724
CAPACITY: 6CENSUS: 5DATE:
11/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Jasbindar Singh, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met Jasbindar Singh, Administrator and explained the purpose of the visit. The facility has a capacity of six (6) to serve residents from age 60 and above which may have six (6) non-ambulatory and approved for four (4) hospice waiver. One (1) resident is on hospice. Annual fee is current. Administrator certificate is current with expiration date on 4/11/25

The visit consisted of the completion of CARE tool, interviews of staff/residents, conduct of physical plant, and reviews of food supply/ medications/ facility records.

This facility is a single story house located in a residential neighborhood in Covina. The facility consisted of five (5) bedrooms which including three (3) resident bedrooms and two (2) staff bedrooms, two (2) bathrooms, office, living room, dining room, kitchen, and back yard. Kitchen was clean and had maintained the required two (2) days perishable and seven (7) days non- perishable. Each resident's bedrooms were furnished with required furniture. Adequate linen and personal hygiene supply were observed. Bathrooms inspected and were clean, operable, with the required grab bars and non-skid materials in the shower. Hot water temperature was measured at 106.9 degrees Fahrenheit which was within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies were observed. Smoke detectors and carbon monoxide detectors were operable. Fire extinguishers were fully charged and last service was on 02/20/24. Fire drill was conducted on 11/19/24. Auditory devices were operable. Medication is centrally stored and current. Resident records were stored in a locked storage room and inaccessible to residents. Facility maintained a comfortable temperature of 73 degrees Fahrenheit for residents. No deficiencies cited per California Code of Regulations, Title 22. An exit interview was conducted. This report is discussed and provided to facility Administrator.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/26/2024
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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