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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366409605
Report Date: 05/16/2022
Date Signed: 05/16/2022 02:05:53 PM

Document Has Been Signed on 05/16/2022 02:05 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:
05/16/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:31 PM
MET WITH:Norma Garcia, care providerTIME COMPLETED:
02:09 PM
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced plan of correction (POC) visit to the facility. This POC was conducted to verify compliance from deficiency citations that were issued on 4/19/2022. LPA met with care provider Norma Garcia.

Health & Safety Code 1569.38 requires the licensee to provide written notification to a resident, the residents' responsible party, if any, and the local long-term care ombudsman within 10 days from the date indicated on the accusation. The licensee is also required to post the accusation in a conspicuous place in the facility.

The date the Accusation was delivered was on 4/8/2022. The licensee had 10 days from this date to notify, in writing, the residents, their responsible parties, and the ombudsman. The 10th day was 4/18/2022. During today's visit, LPA did not observe Accusations posted by the front door. Two of three resident and/or responsible parties deny receiving a written notice regarding the Accusations.

On 4/19/2022, LPA issued a deficiency under Health & Safety Code 1569.38. POC was that Licensee shall post accusations: 8219211401, 8219211401B, 8219211401C and 8219211401D in a conspicuous place and provide written notification to the residents and/or resident's responsible party and local long-term care ombudsman. The following deficiency was not corrected by the POC due date nor at the time of this visit. Civil penalties are being assessed and will continue to accrue until proof of corrections has been submitted.

Civil penalties assessed today at the rate of $100 per day and the assessment of $2100 is for the period of 4/26/22 through 5/16/22. Civil penalties will continue to accrue at rate of $100 until the violation is corrected. This assessment will not exceed $100 per day regardless of the number of notices the licensee fails to send. The total civil penalty for a continuous violation shall not exceed $5,000. ********CONTINUED ON LIC809-C********
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2022
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
, CA 92507
FACILITY NAME: MOUNTAIN VIEW COTTAGES-VI
FACILITY NUMBER: 366409605
VISIT DATE: 05/16/2022
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The civil penalty assessment started on 04/19/2022 and continues until Licensing has received proof that all required parties have received written notification of the revocation action.

Refer to LIC 809D issued on 4/19/2022 for deficiency cited. Civil Penalties assessed today total $2100.

An exit interview was conducted where this report, LIC 421A (civil penalty assessment forms) and appeal rights were discussed. A copy of all reports and forms were provided to care provider, Norma Garcia.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2022
LIC809 (FAS) - (06/04)
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