Mountain View Cottages - V

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required-1 year visit. LPA was met by Eva Nainggolan, Direct Care Staff/DSP II and explained the purpose of the visit. The Administrator, Trupti Mody was called on the phone. The facility is licensed to serve (4) non-ambulatory residents ages 60 and above, of which (1) may be bedridden. Bedroom #5 is approved for the bedridden resident. Facility cares for dementia residents and has a hospice waiver approved for (4) residents. The facility is vendorized 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: Infection control practices and Personal Protective Equipment (PPEs) were maintained. Bathroom has hygiene items such as hand soap and toilet paper. Staff are trained in the proper use of required PPEs. Operational Requirements: A fire clearance is in place. Facility has signal systems in exit points but some are inoperable. Liability of insurance is not readily available for review in the facility. Surety bond is valid in the amount of $3000 and expires on 09/29/2026. There are (2) fire extinguishers in the facility which was last serviced on 02/10/2026. Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood that consists of (4) resident bedrooms, (2) staff bedrooms, (2.5) bathrooms, living room with a fireplace, activity room, kitchen, dining area, backyard with a covered patio and equipped with outdoor furniture and attached garage with a laundry area. 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 video surveillance in the common areas of the facility. Facility has interconnected smoke detectors and carbon monoxide detectors at the home. Knives, cleaning solutions, and disinfectants are locked. Sufficient food supplies are observed. The facility has a dementia care plan to accept or retain residents with dementia. There are no firearms or weapons stored at the facility. Water temperature reading measured at 107 deg F in bathroom #1 and 109.2 deg F in bathroom #2 which are within the required 105 - 120 degrees Fahrenheit. *****REPORT CONTINUED ON LIC809-C**** Staffing: A total of six (6) 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. LPA observed that food containers inside the refrigerator were not labeled. Incidental Medical Services: Medications reviewed for all (4) residents. Residents have Restricted Health Care Plan and Needs and Services Plan on file. Currently, (1) resident is bedridden and under hospice care. Residents medication are centrally stored in a locked cabinet in the kitchen area. Resident Records-Incident Reports: All (4) 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 that the bedtime medications for (1) resident was administered on the evening of 02/16/2026, however, the staff failed to sign/initial the Medication Administration Record (MAR). 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 Advisories were issued. Exit interview and a copy of this report along with the appeal rights were provided to Paran Mody, Administrative Assistant.the state’s words, verbatim · CDSS document, Feb 17, 2026

The state marks this report as 9 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 3/14/25. LPA arrived unannounced and met with Staff, Eva Nainggolan. 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. Bedroom #5 is approved for the bedridden resident. There is a hospice waiver approved for 4 residents. The facility is vendorized by the San Gabriel/Pomona Regional Center. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools to inspect the facility today. The single story facility consists of 4 resident bedrooms, 2 staff rooms, 2.5 bathrooms, living room, dining room, kitchen, and attached garage. Fireplace is secured by a fence. There are video surveillance in the common areas of the facility. Facility has interconnected smoke detectors and 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. Sufficient food supplies are observed. The facility has a dementia care plan to accept or retain residents with dementia. LPA reviewed 3 personnel files. Staff employed have fingerprint clearance and associated to the facility. The files contain the personnel record, health assessment, TB test results, and annual training hours. Staff have current CPR & First aid certificates. LPA reviewed all 4 resident files. The files are also maintained at the facility and have the following documents in their files such as Admission Agreements, Identification & Emergency Information, Physician's Report, Regional Center's IPP reports, and Resident rights. Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical/mental capability. Medications are centrally stored in the kitchen cabinet and they are being administered as prescribed by the physician. The updated Emergency Disaster Plan is reviewed annually by the administrator. However, LPA provided a technical violation for the emergency disaster drills. There are no deficiencies issued today. An exit interview was held and a copy of this report was emailed to the administrator.the state’s words, verbatim · CDSS document, Mar 14, 2025

The state marks this report as 2 pages; the online copy we transcribed has 1. 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 3/5/24. LPA arrived unannounced and met with Staff, Eva Nainggolan. 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 non-ambulatory residents ages 60 and over, of which 1 may be bedridden. Bedroom #5 is approved for the bedridden resident. The facility serves developmentally disabled residents who are placed by the San Gabriel/Pomona Regional Center. There are currently 3 non-ambulatory and 1 ambulatory residents residing at the facility. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools and observed the following: The single story facility consists of 4 resident bedrooms, 2 staff rooms, 2.5 bathrooms, living room, dining room, kitchen, and attached garage. The fireplace is secured by a fence. There are no swimming pool or bodies of water on the premises. Facility has interconnected 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. The hot water temperature was measured between the required range of 105-120 degrees F. The facility staff are using appropriate hand hygiene and wearing gloves while assisting residents. The facility has a dementia care plan to accept or retain residents with dementia. LPA reviewed 4 personnel files. Staff employed have fingerprint clearance and associated to the facility. They have the required documents and training hours in their files. Staff have current CPR & First aid certificates. Resident files are also maintained at the facility and have the following documents in their files such as Admission Agreements, Identification & Emergency Information, Physician's Report, Regional Center's IPP reports, and Resident rights. The Complaint poster, Local Ombudsman, and Residents personal rights are posted. Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical/mental capability. There are sufficient food supplies of 2-day perishable and a week of non-perishable items. The food are properly stored in the refrigerator. Medications are centrally stored in the kitchen cabinet. LPA reviewed 4 resident medications and they 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, Mar 5, 2024