Mountain View Cottages - II

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cynthia Chan conducted the annual inspection on 9/10/26. LPA met with Staff Miho Suzuki and explained the reason for the visit. The facility is licensed to serve (4) residents ages 60 and over, of which (3) may be non-ambulatory and (1) bedridden. Bedridden is approved in bedroom #1. The hospice waiver is approved for (4) residents. The facility is vendorized by the San Gabriel/Pomona Regional Center. There are currently (2) residents residing at the facility. The facility consists of (7) bedrooms and (3) bathrooms at the facility. The resident rooms are approved for bedroom #1, #2, and #3, which is to the right of the entry. Bedroom #4 is designated as the staff room. Bedroom #1 has a private bathroom. All 3 resident bedrooms have exit doors with auditory alarm device installed. Bedrooms #5, #6, and #7 located to the left side of the home are designated as staff rooms. LPA observe sufficient food supplies. There is a carbon monoxide detector in the kitchen area and smoke detectors located throughout the facility. The hot water temperature was measured within the 105-120 degrees F. Sufficient hygiene supplies and clean linens are observed. The liability insurance is maintained with the required amount. LPA reviewed (2) resident files and the required documents are observed. The medications were reviewed and given as prescribed. LPA reviewed (2) staff files. The administrator's certificate expires on 5/31/28. Staff have current CPR & First Aid certificates and are receiving annual training. The Emergency Disaster Plan has relocation sites and emergency procedures. Drills are being conducted quarterly. No deficiencies were issued today. An exit interview was held and a copy of this report was given to the administrator.the state’s words, verbatim · CDSS document, Sep 10, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required-1 year visit. LPA was met by Primitivo Serame, DSP I & II and Cherry Serame, DSP I & II and explained the purpose of the visit. The Administrator was called on the phone who informed LPA that she is out of the area and unable to assist. The facility is licensed to care for (4) residents ages 60 and above and one may be bedridden. Bedridden fire clearance approved for bedroom #1 only. Approved to care for (4) hospice residents. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were maintained. Bathroom has hygiene items such as paper towel, hand soap and toilet paper. Staff are using appropriate hand hygiene and wearing gloves while assisting residents. Operational Requirements: A fire clearance is in place. Facility has working signal systems in exit points. Liability Insurance policy is valid and will expire on 02/15/2026. There are (2) fire extinguishers in the facility which was last serviced on 02/18/2025. Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood that consists of (7) bedrooms, (3) bathrooms, living room with a fireplace, kitchen, dining area, family room, laundry area in the hallway, backyard with sitting area and attached garage. The facility is only using the bedrooms to the right of the house for residents, of which (3) bedrooms are for residents, (1) for staff, and (2) bathrooms. The other side of the house consists of 3 bedrooms dedicated as staff rooms and (1) bathroom. garage. Currently, there are two (2) residents in the facility. The interior and exterior physical plant was inspected. Resident bedrooms were toured. Each bedroom has a smoke detector, linen, light, chair and sufficient closet space. There are (2) carbon monoxide detectors at the home. Backyard was inspected and does not have a shaded area. There are no firearms or weapons stored at the facility. Water temperature reading measured 107.6 deg F in bathroom #1 and 109.2 deg F in bathroom #2 which is within the required 105 - 120 degrees Fahrenheit. *****REPORT CONTINUED ON LIC809-C**** Staffing: A total of five (5) staff members including the Administrator provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have the required training and associated to the facility. Personnel Records/Staff Training: Administrator's proof of health clearance, fingerprint clearance, vaccinations and 1st Aid/CPR training are current. Administrator's certificate is valid and expires on 05/31/2026. Resident Rights-Information: Rights of individuals with disabilities are posted. Facility provides internet services to all residents and have access to the facility phone. Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. Food Service: The kitchen was inspected and has sufficient supply of 2-day perishable & 7 day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. LPA observed that some food containers inside the refrigerator were not covered nor labeled. Incidental Medical Services: Medications reviewed for (2) residents. Residents have Restricted Health Care Plan and Needs and Services Plan on file. Currently, (1) resident is under hospice care and (1) resident receive Home Health care in the facility. Residents medication are centrally stored in a locked cabinet in the kitchen area. Resident Records-Incident Reports: Two (2) resident files were reviewed containing admission agreements, Physician's Report, Medical/Functional assessments, Needs and Services Plans, TB clearance, Personal rights, Medical Consent, Medication Records, Restricted Health Care Plans and Hospice Notes/Records were reviewed. During medication review, LPA observed the staff failed to sign/initial the Medication Administration Record (MAR) on the correct dates, 09/15/2025 (PM) and 09/16/2025 (AM) for the medications administered for (2) residents. Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan. The facility conducts emergency drill on a quarterly basis. Last fire drill was conducted on 07/18/2025. Residents with SHN: One (1) resident receive hospice care. Appraisals were observed in resident files. Deficiency cited and Technical Assistance issued. Exit interview and a copy of this report along with the appeal rights were provided to Cherry Serame, DSP II.the state’s words, verbatim · CDSS document, Sep 16, 2025

The state marks this report as 6 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cynthia Chan conducted the annual inspection on 8/27/24. LPA arrived unannounced and met with Staff, Cherry Serame. The purpose for the visit was explained. Administrator, Trupti Mody, arrived shortly after to assist with the visit. The facility is licensed to serve (4) residents ages 60 and over, of which 3 may be non-ambulatory and 1 bedridden. Bedridden is approved in master bedroom #1. There is an approved hospice waiver for 4 residents. The facility is vendored by the San Gabriel/Pomona Regional Center. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools to inspect the facility. The single story facility consists a total of 7 bedrooms. However, the facility is only using the bedrooms to the right of the house for residents, which 3 bedrooms are for residents, 1 for staff, and 2 bathrooms. The other side of the house consists of 3 bedrooms dedicated as staff rooms and 1 bathroom. There is also a living room, dining room, kitchen, laundry room, and attached garage. Food supplies are adequate. The fireplace is not in use and is secured by a fence. There are no swimming pool or bodies of water on the premises. Facility has a smoke detector in each room and 2 carbon monoxide detectors at the home. Knives, cleaning solutions, and disinfectants are locked. The hot water temperature was measured between the required range of 105-120 degrees F. Staff are continuing to follow their infection control plan and wearing gloves while assisting residents. LPA reviewed 2 personnel files. The administrator's (Trupti Mody) certificate has expired but verified that the renewal documents have been received. Staff have the required documents and training hours in their files. Staff have current CPR & First aid certificates. LPA reviewed 2 Resident files and they also have the required documents. The Complaint poster, Local Ombudsman, and Residents personal rights are posted. Facility has sufficient space to accommodate indoor and outdoor activities. Medications are centrally stored in the kitchen cabinet. LPA reviewed 2 resident medications and are being administered as prescribed. The facility has the Emergency Disaster Plan with contact numbers, at least 2 relocation sites, and procedures in case of emergency. There are no deficiencies issued today. An exit interview was held and a copy of this report was given to administrator Trupti.the state’s words, verbatim · CDSS document, Aug 27, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Cynthia Chan conducted a case management visit in response to an incident report sent to licensing on 11/20/23. LPA arrived unannounced and met with Staff, Cherry Serame. The purpose of the visit was explained. The incident report indicated that Resident #1 (R1) developed a wound on 11/20/23 that was unstageable at the time. During the visit today, LPA reviewed medical notes and interviewed staff. Staff interviewed stated that they first noticed redness on the right buttock of R1 on 11/10/23. They immediately informed the administrator who contacted the home health agency. On 11/13/23, a home health nurse conducted the initial visit to evaluate and treat the wound. Based on the Omni Home Health progress notes dated 11/24/23, the wound on the right hip was evaluated as a stage 3. The nurse had recommended to turn R1 every 2 hours and to keep the skin clean and dry. Additional progress notes dated 12/1/23 and 12/5/23 indicated the pressure ulcer was at stage 4. R1 was transferred to a Skilled Nursing Facility as initiated by the Regional Center personnel on 12/6/23. Staff interviewed stated R1 was not on hospice and the wound appeared to be healing while in care. They also stated R1 was turned every 2 hours. However, at night, a staff would check on R1 once, between 8pm - 6am, and turn R1 at that time. Based on the information gathered, the facility retained resident with a stage 3 or 4 wound which is considered a prohibited health condition. Therefore, a deficiency is being cited on the LIC809D. An exit interview was held and a copy of this report along with appeal rights were given to the administrator.the state’s words, verbatim · CDSS document, Dec 12, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(1) · Plan of correction due date: Dec 13, 2023

87615 Prohibited Health Conditions (a) Persons who require health services for or have a health condition...shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. This requirement is not met as evidenced by: Based on interview and records review, the facility retainedthe state’s words, verbatim · CDSS document, Dec 12, 2023

Plan of correction: The licensee shall review the prohibited health conditions regulation and shall not retain a resident with staff 3 and 4 pressure injuries. Resident #1 shall be transferred out of the facility by POC due date 12/13/23. **This deficiency has been cleared today as R1 had been relocated to a SNF.

Allegation investigated: Facility staff flicked resident in care.

Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation for the above allegation. LPA arrived unannounced and met with Staff, Eva Nainggolan. Administrator, Trupti Mody, could not be present at the facility, therefore, the purpose of the visit was explained via telephone. LPA obtained a copy of the staff and resident rosters. Interviews were held with the Administrator via telephone, 5 Staff (Staff #1 - #5), and 3 Residents (Resident #1 - #3). Allegation – Facility staff flicked a resident in care. It is alleged that Staff #1 (S-1) flicked Resident #1 (R-1) on the forehead. Administrator stated an interval investigation was conducted and S-1 admitted to flicking R-1 on the head. During the visit today, LPA interviewed Staff and Residents. S-1 admitted to flicking R-1 by the ear and stated it was a one time occurrence. S-1 indicated the flick was not hard as staff was doing so playfully. Substantiated LPA attempted to interview R-1 regarding this incident but was unsuccessful. LPA interviewed the other 2 residents, of which one witnessed S-1 flicking R-1 on the head while sitting at the dining table. Based on interviews conducted, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted. The Plan of Corrections were reviewed and developed with the administrator via telephone. A copy of this report and appeal rights were provided. During the visit today, LPA interviewed (S-1) who denied smacking R-1 on the head. Other staff did not witness S-1 hitting any residents. They stated they treat residents with respect and would not hit a resident. R-1 was interviewed and responded yes to staff hitting resident. However, R-1 could not provide any details regarding incident. Additional residents interviewed have not observed S-1 or any other staff hitting another resident. LPA did not observe any bruises or marks on R-1. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with staff Cherry Serame. A copy of this report along with the appeal rights were provided.the state’s words, verbatim · CDSS document, Nov 15, 2023 · control 28-AS-20231108132115

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Nov 16, 2023

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff... This requirement is not met as evidenced by: Based on interviews, staff flicked resident on the head which posed an immediate personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 15, 2023

Plan of correction: The administrator shall conduct an in-service training with staff regarding personal rights by POC due date 11/16/23.