Mountain View Cottages - V

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cynthia Chan conducted the required annual inspection. LPA arrived unannounced and met with Staff, Eva Nainggolan, who allowed entry. The purpose for the visit was explained. The facility is licensed to serve 4 non-ambulatory residents ages 60 and over, of which 1 may be bedridden. The bedridden resident is approved for bedroom #5. The facility serves developmentally disabled residents who are placed by the San Gabriel/Pomona Regional Center. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting residents. Staff are cleaning and disinfecting at least every 2 hours. Facility has sufficient PPE supplies and submitted an Infection Control Plan. Operational Requirements: The facility has a dementia care plan to accept or retain residents with dementia. There are currently 3 non-ambulatory and 1 ambulatory residents residing at the facility. Physical Plant & Environment Safety: The facility has no swimming pool or bodies of water on the premises. The fireplace is not in used and is fenced. There are 4 resident bedrooms, 1 live-in staff room, 1 vacant room, 3 bathrooms, living room, dining room, kitchen, and an attached garage. Facility has an operable smoke detector in each room and 2 carbon monoxide detectors at the home. Knives, cleaning solutions, and disinfectants are locked, making them inaccessible to residents. There are no firearms or weapons stored at the facility. The hot water temperature was measured between the required range of 105-120 degrees F. Staffing: There is sufficient staffing at the facility. Staff employed have fingerprint clearance and associated to the facility. Personnel Records-Training: Staff files are maintained at the facility. Staff have current CPR/first aid training and sufficient on-going training that meets the annual requirement. Resident Records-Incident Reports: Resident files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, Physician's Report, Regional Center's IPP reports, and Resident rights. Resident Rights-Information: The Complaint poster, Local Ombudsman, and Residents personal rights are posted. Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical/mental capability. Food Service: There are sufficient food supplies of 2-day perishable and a week of non-perishable items. The food are properly stored in the refrigerator. Incidental Medical & Dental: The medications are centrally stored and in their original bubble packs. The facility uses the Medication Administration Record (MAR) log to document medications given. LPA reviewed all 4 residents' medications and they are being administered as prescribed by the physician. Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Residents with Special Health Needs: The facility accepts and retains residents with dementia and/or hospice. The staff received training on appropriately caring for residents with dementia. LPA interviewed 2 Staff and a resident during the visit. No deficiencies were issued today. Technical advisories were provided. An exit interview was held. A copy of this report, technical advisory notes, and appeal rights were given to Staff Anwar.the state’s words, verbatim · CDSS document, Apr 10, 2023

Type of visit: Case Management - Licensee Initiated

Licensing Program Analyst (LPA) Cynthia Chan conducted a case management visit for a capacity change. LPA met with Administrator Trupti Mody. The licensee initiated a capacity change from 6 to 4. The fire clearance was approved on 10/26/22 for a total of 4 developmentally disabled residents, ages 60 and above: (3) non-ambulatory and (1) bedridden. Only (1) bedridden resident is approved for room #5. Rooms #2, #3, #4, and #5 are designated as resident rooms. All 4 residents were placed by the San Gabriel/Pomona Regional Center. LPA toured the facility and observed the following: * Rooms #2, #3, #4, and #5 are occupied by residents. Each resident currently has their own room and has the required furniture. * Room #1 is being used as storage and will be used as a staff room. * The room next to the kitchen is used by the live-in staff. * There are extra clean linens and towels for residents. * There are tables and chairs set up for 4 residents. * The food supplies are sufficient for the current census. An exit interview was conducted. A copy of this report was given to Administrator Mody.the state’s words, verbatim · CDSS document, Mar 13, 2023

Allegation investigated: Facility staff are not wearing masks.

LPA made initial 10 day visit to investigate the above allegation. LPA was greeted by DSP Siaful Anwar and Administrator showed up about 1 hour later. Regarding the Allegation: Facility staff are not wearing masks. When LPA arrived at facility and was greeted by S1, S1 was wearing a mask. LPA interviewed 3 staff (S1-S3) and 2 residents (R1-R2) R3 and R4 were not able to answer questions. 3/3/ staff stated they always wear mask on duty. 2/2 residents interviewed stated staff are always wearing mask. LPA observed all three staff wearing mask during entire visit. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview was conducted, a copy of this report and Appeal Rights were provided to Administrator Unsubstantiated Regarding Allegation: Facility does not have phone service. LPA attempted to call facility on 01/10/2023 and phone was not working. 3/3 staff interviewed stated that phone was out of order until 01/11//2023. S2 stated that phone was not working for a while. S3 acknowledged that phone was not working and stated reason was not known. 1/2 residents stated facility has working phone now. 1/2 resident reported that phone was not working for about 1 week. LPA called the facility phone during the visit and it was functioning properly. Based on LPAs observations and interviews which were conducted and recorded, the preponderance of evidence standard has been met, therefore the above allegations are found to be Substantiated. Deficiencies cited, Please see 9099D for detailsthe state’s words, verbatim · CDSS document, Jan 12, 2023 · control 28-AS-20230105100553

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jan 26, 2023

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provisions of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met by evidence of: LPA and S1 observed living and dead roaches in the kitchen cabinets and surrounding area.the state’s words, verbatim · CDSS document, Jan 12, 2023

Plan of correction: Administrator will contact the licensee and ask for treatment of the roach infestation. Administrator will send copy of invoice or proof that professional pest control has rendered services and send proof to LPA by POC dated.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87311 · Plan of correction due date: Jan 13, 2023

All facilities shall have telephone services on the premises. This requirement is not met by evidence of: LPA attempted to call on 01/10/2023 and phone was not working. 2 staff and administrator stated phone was not working for some time.the state’s words, verbatim · CDSS document, Jan 12, 2023

Plan of correction: Administrator will make sure facility has working phone services at all times, , ****Phone service at facility was working properly during visit and no further action is required.****

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with Staff, Eva Nainggolan who assisted with visit and spoke with Administrator, Trupti Mody, via phone call during the visit. Facility serves. Facility is licensed to serve six (6) non-ambulatory, developmentally disabled residents who are age 60 and above. Annual licensing fees is current. Administrator certificate is current and the expiration date is 05/31/2022. All current residents were placed by San Gabriel/Pomona Regional Center (DD - Level IV (C) clients. During the visit, the infection control domain tool was used, a tour of the facility was conducted, food supply was reviewed, and medications were reviewed. The facility is located in a residential neighborhood. LPA toured the facilities physical plant, indoor and outdoor. The facility has five (5) resident bedrooms and one (1) staff bedroom, two (2) full bathrooms, one (1) half bathroom, living area, kitchen, dining room, and an indoor/covered outdoor activity area. All the rooms were furnished with appropriate furniture for residents’ comfort. The bathrooms were furnished with grab bars and nonskid surfaces. Common areas were observed for the ability to safely serve the needs of the residents. Hot water temperature was 113.6 degrees Fahrenheit which was within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies was observed. No pools and bodies of water on the premises. Facility maintained a comfortable temperature for residents. Auditory alarm devices to monitor exits were operable. Interior and exterior space available to permit residents to wander freely and safely. Sufficient supply of perishable and nonperishable foods is observed. Knives, tools, sharp items are inaccessible to residents. Smoke detectors and carbon monoxide detectors are operable. Fire extinguishers’ last service is 01/26/22 and are fully charged. ( - Continued in LIC 809 C-) The first aid kit is fully stocked. Mandated documents and signages are posted in common areas. The outdoor activity area has a shaded patio with ample seating. Medication are centrally stored in a locked cabinet in the kitchen and inaccessible to residents. Resident records are stored in a locked cabinet and inaccessible to residents. Toxic substances are inaccessible to residents. Outdoor facility space used for residents and leisure are completely enclosed by a fence with self-closing gates. Deficiencies were observed and cited per California Code of Regulations, Title 22 in LIC 809 D. An exit interview was conducted. This report was discussed with Administrator, Trupti and Staff, Eva. Staff’s signature on this form confirm receipt of these documents. A copy of LIC 809s report and appeal rights were provided.the state’s words, verbatim · CDSS document, Mar 25, 2022