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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204376
Report Date: 12/16/2025
Date Signed: 12/16/2025 03:12:19 PM

Document Has Been Signed on 12/16/2025 03:12 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 - 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: 4DATE:
12/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:14 PM
MET WITH:Administrator- Jasbindar SinghTIME VISIT/
INSPECTION COMPLETED:
03:35 PM
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Licensing Program Analyst (LPA) Vaid conducted an unannounced Annual Required 1-year visit. Staff person Fiviyanti Lo allowed entry into facility. LPA was met by Administrator Jasbindar Singh and explained the purpose of the visit. The facility is licensed to serve six (6) non ambulatory residents over the age of 60 and has an approved hospice waiver for four (4). Currently one(1) resident is under hospice.

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.

Physical Plant: The facility is a single-story dwelling located on a main street with three (3) resident bedrooms, two (2) staff bedrooms, two (2) bathrooms, kitchen, dining room, living room, front yard, backyard, and attached garage. Front yard was clean and well maintained. LPA Vaid observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Vaid observed knives and sharps located in kitchen cabinet, to be inaccessible to residents in care. Kitchen sink water temperature was measured at 114.2 degrees F. Kitchen appliances were observed to be clean and in working order. Dining room was observed to be clean and contained one table with plenty of seating. Living room was observed to have plenty of seating and lighting. Interior temperature measured at 78 degree F. Backyard was clean and well maintained. Plenty of shade and seating was observed.

Linen Closet: Contained plenty linens, towels, and hygiene products.

Resident Rooms : LPA Vaid inspected three (3) resident bedrooms and observed all bedrooms to contain required furnishings, lighting, and linens.
CONTINUED ON PAGE 809C..........
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2025
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 - IV
FACILITY NUMBER: 198204376
VISIT DATE: 12/16/2025
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Bathrooms: Water temperature in both resident bathrooms were within 105-120 degrees F. LPA observed grab bars and shower chair and non skid mats.

Emergency Drills: Last documented drill was conducted on 10/08/2025 at 2 pm.

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide in hallways and smoke detectors were observed to be operable.


Resident /Staff Files: Four (4) resident files were reviewed. LPA Vaid reviewed staff files for three (3) staff. Personnel records are maintained at facility.

Liability Insurance & Infection Control Plan: Facility has current liability insurance on file. LPA Vaid observed updated infection control plan.

Laundry Room: LPA Vaid observed laundry room operational and clean, toxins are locked and inaccessible to residents in care.


No deficiencies cited per California Code of Regulations, Title 22. An exit interview was conducted.
This report is discussed and provided to facility Administrator.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2025
LIC809 (FAS) - (06/04)
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