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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198204377
Report Date: 02/13/2023
Date Signed: 02/13/2023 03:38:23 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/10/2023 and conducted by Evaluator Cynthia D Chan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230210100952
FACILITY NAME:MOUNTAIN VIEW COTTAGES - IFACILITY NUMBER:
198204377
ADMINISTRATOR:PRISCO CASTILLOFACILITY TYPE:
740
ADDRESS:1147 CLEGHORN DR.TELEPHONE:
(909) 861-8508
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY:6CENSUS: 3DATE:
02/13/2023
UNANNOUNCEDTIME BEGAN:
12:44 PM
MET WITH:Octavia Lapalonga, StaffTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Facility is in disrepair.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation for the allegation listed above. LPA arrived unannounced and met with Staff, Octavia Lapalonga. The purpose of the visit was explained. Administrator, Jasbindar Singh, arrived shortly thereafter to assist with the visit.

The investigation consisted of the following:
LPA obtained copies of the staff roster, resident roster, and interviews held with the Administrator, 3 Staff, 2 residents, and a plumber. A tour of the facility was also conducted.

For allegation – Facility is in disrepair. It is alleged a pipe burst, causing mold, and the water was turned off. Facility staff indicated the water leak occurred approximately 2 weeks ago. The incident was reported to the owner right away. Due to obtaining cost and securing a plumber, the repair began this past Saturday, 2/11/23 and the anticipated completion date is on 2/17/23.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 28-AS-20230210100952
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 - I
FACILITY NUMBER: 198204377
VISIT DATE: 02/13/2023
NARRATIVE
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LPA toured the facility and observed the walls striped apart in the bathrooms, laundry area, and hallway to repair the pipes. LPA did not see any mold, but the water was turned off. Staff indicated that they were instructed to keep the water off for the time being and to turn on only when showering, using the toilet, or washing hands. Per the Administrator, several gallons of water are being refilled so that residents and staff could use for washing things. Residents interviewed were not aware of the water pipe bursting and causing leaks.

Based on interviews and observation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC 9099D.

An exit interview was conducted. The Plan of Corrections were reviewed and developed with the Administrator. A copy of this report and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20230210100952
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 - I
FACILITY NUMBER: 198204377
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/20/2023
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation (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.
The requirement is not met as evidenced by:
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The Administrator shall submit proof of repair for the bathrooms, laundry area, and hallway by POC due date 2/20/23.
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Based on interviews conducted, the water was turned off due to the water pipes being in disrepair which poses a potential health and safety risk to residents in care.
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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.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3