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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336412145
Report Date: 09/09/2022
Date Signed: 09/09/2022 11:43:52 AM

Document Has Been Signed on 09/09/2022 11:43 AM - 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:MOUNTAIN VIEW RESIDENTIAL CARE FOR THE ELDERLYFACILITY NUMBER:
336412145
ADMINISTRATOR:MARIA ELIZABETH PELAYOFACILITY TYPE:
740
ADDRESS:78805 NOLAN CIRCLETELEPHONE:
(760) 200-5366
CITY:LA QUINTASTATE: CAZIP CODE:
92253
CAPACITY: 6CENSUS: 6DATE:
09/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Maria Elizabeth Pelayo - AdministratorTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of completing the facility's Annual Inspection. LPA Colvin met with Administrator Maria Elizabeth Pelayo and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. Below is a summary of what was observed:

Infection Control: LPA Colvin went over COVID-19 best practices for infection control and prevention with Administrator Maria Elizabeth Pelayo, who LPA Colvin found to be successfully incorporating the several aspects of the facility's Mitigation Plan. Residents have hand sanitizer available to them, and the bathrooms were stocked with hand soap and paper towels. While touring the facility, LPA Colvin observed postings throughout the facility for cough etiquette, social distancing, and infection control. When LPA Colvin had approached the door of the facility initially, LPA Colvin observed a sign on the door stating that no visitors were permitted due to COVID-19. LPA Colvin confirmed with Administrator and staff that they are in fact allowing visitation, so LPA Colvin recommended that they remove the sign from the door immediately. LPA Colvin requested to view the facility's PPE supplies (gloves, masks, and sanitizer, and isolation gowns) which LPA Colvin observed to be sufficient for a 30-day supply. LPA Colvin went over the various recommended training for facility staff with Administrator Administrator Maria Elizabeth Pelayo in relation to COVID-19 and confirmed that staff have been trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing PPE.

LPA Colvin inquired as to if staff have been fit tested for N95 masks, and Administrator Administrator Maria Elizabeth Pelayo confirmed that they have conducted fit testing for all staff. LPA Colvin was informed that all staff have been vaccinated, so the facility is no longer conducting surveillance testing for COVID-19 for staff. In addition to going over the facility's policy for testing staff and residents for COVID-19, LPA Colvin also inquired about if the facility is still screening their residents daily for COVID-19 symptoms, which includes checking their temperature.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MOUNTAIN VIEW RESIDENTIAL CARE FOR THE ELDERLY
FACILITY NUMBER: 336412145
VISIT DATE: 09/09/2022
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Administrator Administrator Maria Elizabeth Pelayo confirmed that staff are continuing to monitor residents’ symptoms, and that both staff and visitors are screened for COVID-19 symptoms prior to entering the facility. LPA Colvin additionally observed a sign-in log for visitors, where their temperature is recorded as well as answers to screening questions. LPA Colvin observed PPE stored at the entrance to the facility for staff and visitor use, if needed.

An exit interview was conducted with Administrator Administrator Maria Elizabeth Pelayo and a copy of this report was provided.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2022
LIC809 (FAS) - (06/04)
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