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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204377
Report Date: 12/06/2024
Date Signed: 12/06/2024 05:50:21 PM

Document Has Been Signed on 12/06/2024 05:50 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 - IFACILITY NUMBER:
198204377
ADMINISTRATOR/
DIRECTOR:
PRISCO CASTILLOFACILITY TYPE:
740
ADDRESS:1147 CLEGHORN DR.TELEPHONE:
(909) 861-8508
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY: 6CENSUS: 6DATE:
12/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Jennifer Discipulo, CaregiverTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cynthia Chan conducted the unannounced annual inspection on 12/6/24. LPA met with Staff, Jennifer Discipulo, and explained the reason for the visit. Administrator, Jas Singh, arrived shortly after to assist with the visit. The facility is licensed to serve 6 non-ambulatory residents ages 60 and over. There is an approved hospice waiver for 6 residents.

LPA conducted a tour, reviewed files and medications using the Compliance and Regulatory Enforcement (CARE) tools.
The faciity consists of 5 resident bedrooms, 1 staff room, 3 bathrooms, living room, dining room, family room, kitchen, and laundry area. The backyard has a shaded area with table and chairs for residents to use. The bedrooms have sufficient storage space and lighting. Bathrooms have grab bars and non-skid mats. There are extra clean linens stored in the cabinet. Knives and cleaning products are locked. There is a carbon monoxide detector located near the kitchen and smoke detectors are operable. Sufficient food supplies are observed. The hot water temperature was measured at 127.4 degrees F which is above the required range.
LPA reviewed all 6 resident files and their medications. The files contain the required documents and medications are being given as prescribed. The resident rights, local ombudsman, and licensing posters are located in a prominent area. LPA reviewed 3 personnel files. The administrator's (Jas Singh) certificate expires on 4/11/25. Staff have current CPR & First Aid certificates. Files contain the health screening with TB test results, personnel report, and annual training verification.
Facility accepts and retains residents with dementia. There are no residents on hospice at this time but some are receiving home health services. No residents have a restricted or prohibited health condition. The facility has the updated Emergency Disaster Plan and signed annual by the administrator. Disaster drills are being provided to staff.
A deficiency is being issued on the LIC809D. An exit interview was held and a copy of this report was given to the administrator.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2024
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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Document Has Been Signed on 12/06/2024 05:50 PM - It Cannot Be Edited


Created By: Cynthia D Chan On 12/06/2024 at 12:25 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 - I

FACILITY NUMBER: 198204377

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 12/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
87303(e)(2) Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows:
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in which bathrooms were measured at 127.4 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/07/2024
Plan of Correction
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Administrator shall adjust the hot water temperature and measure the water temperature several times to ensure it stays within the required range of 105-120 degrees. The water temperature log shall be submitted to LPA by 12/7/24.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2024


LIC809 (FAS) - (06/04)
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