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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366409605
Report Date: 04/25/2022
Date Signed: 04/25/2022 01:26:59 PM

Document Has Been Signed on 04/25/2022 01:26 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:MOUNTAIN VIEW COTTAGES-VIFACILITY NUMBER:
366409605
ADMINISTRATOR:MODY, TRUPTIFACILITY TYPE:
740
ADDRESS:6619 AMBERWOOD DRTELEPHONE:
(909) 980-4028
CITY:ALTA LOMASTATE: CAZIP CODE:
91701
CAPACITY: 6CENSUS: 3DATE:
04/25/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:02 AM
MET WITH:Norma Garcia, care providerTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Anna Bueno conducted a case management visit on this day. LPA was met by staff as administrator was not available. Staff stated they sent a text message to Administrator. During today's visit, LPA and staff toured the outdoor area of the facility.

LPA and staff made observations to the access to and the exterior of the facility structure. Plan of Correction (POC) was discussed telephonically with Administrator during today's visit.

LPA made observations and found issues listed below:
  1. Wooden pallets and/or fencing, a side table withe two drawers, and stacked plastic containers with black bags on the exterior of the right perimeter fence. A mattress frame was observed next to the perimeter gate, next to the trash bins.
  2. The dining/common area screen door to the backyard the is off the track. LPA and staff were unable to close and/or open the screen door with ease as the door drags on the ground.
  3. There is an outdoor seating area but it is not shaded.

Refer to LIC 809D for deficiencies cited. An exit interview was conducted where this report, LIC 809D, and appeal rights were discussed and provided to Norma Garcia.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 04/25/2022 01:26 PM - It Cannot Be Edited


Created By: Anna Bueno On 04/25/2022 at 12:31 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
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: MOUNTAIN VIEW COTTAGES-VI
FACILITY NUMBER: 366409605

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/07/2022
Section Cited
CCR
80087(a)

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BUILDINGS AND GROUNDS: The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
This requirement was not met as evidenced by:
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Licensee shall arrange for the debris to be picked up by a sanitation crew no later than the end of day of 5/7/22. Proof shall be provided to the Department no later than 5/7/22.
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LPA and staff observed debris (wooden pallets, side/end table, plastic containers and bags, mattress) were observed on the facility.
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Type B
05/26/2022
Section Cited
CCR87303(a)

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MAINTENANCE/OPERATION: The facility shall be clean, safe, sanitary, in good repair at all times. Maintenance shall include provision of maintenance services, procedures for the safety and well-being of residents, employees, visitors.
This requirement was not met as evidenced by:
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Licensee shall arrange for a properly aligned and adjusted dining/common area screen door no later than the end of day of 5/26/22. Proof shall be provided to the Department no later than 5/26/22.
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LPA and staff observed the dining/common arear screen door off track. LPA snd staff were not able to close and/or open the screen door without the door going off track.
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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:Nedra Brown
LICENSING EVALUATOR NAME:Anna Bueno
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 04/25/2022 01:26 PM - It Cannot Be Edited


Created By: Anna Bueno On 04/25/2022 at 12:56 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
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: MOUNTAIN VIEW COTTAGES-VI
FACILITY NUMBER: 366409605

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/07/2022
Section Cited
CCR
87219(h)(2)

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PLANNED ACTIVITIES: Facilities shall provide sufficient space to accommodate both indoor and outdoor activities...(2) Outdoor activity areas...easily accessible to residents...Gardens or yards shall be sufficient in size, comfortable, appropriately equipped for outdoor use.
This requirement was not met as evidenced by:
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Licensee shall provide appropriate shaded outdoor area for resident use no later than the end of day of 5/7/22. Proof shall be provided to the Department no later than 5/7/22.
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LPA and staff observed outdoor seating that does not have shade.
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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:Nedra Brown
LICENSING EVALUATOR NAME:Anna Bueno
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2022


LIC809 (FAS) - (06/04)
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