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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366409605
Report Date: 08/14/2023
Date Signed: 08/14/2023 02:58:28 PM

Document Has Been Signed on 08/14/2023 02:58 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: 4DATE:
08/14/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:36 PM
MET WITH:Agnes Edi - Direct Support ProviderTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced Proof of Correction (POC) visit for deficiency cited on form LIC9099-D issued on 07/28/2023.

During this visit, LPA inspected the physical plant and observed that Staff 1 (S1) is separated from this facility. LPA conducted staff and resident interviewed that acknowledged S1 was disassociated to the facility.

Letter of Cleared POC was issued during today's visit. This report was reviewed with, and a copy was provided to Agnes Edi
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 08/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2023
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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