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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191222411
Report Date: 10/29/2021
Date Signed: 10/29/2021 01:08:06 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:MONTE VISTA GROVE HOMESFACILITY NUMBER:
191222411
ADMINISTRATOR:DEBORAH A HERBERTFACILITY TYPE:
741
ADDRESS:2889 SAN PASQUAL STREETTELEPHONE:
(626) 796-6135
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY:26CENSUS: 23DATE:
10/29/2021
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
10:02 AM
MET WITH:Deborah Herbert - Licensee and Meagan Swan AdministratorTIME COMPLETED:
11:30 AM
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An informal office meeting was conducted via Microsoft Teams with Regional Manager(RM) Araceli Ramirez , Licensing Program Manager(LPM) Fernando Fierros , Licensing Program Analyst(LPA) Mary Flores , Staff Service Manager I Allison Nakatomi CDSS, Staff Service Manager II Hao Nguyen , Geraldine Regional Manager Department of Public Health Yamakawa Geraldine, Deborah Herbert Licensee/Administrator and Megan Swan Assistant Administrator regarding facilities change of Skill Nursing Facility(SNIF) into a Residential Care for the Elderly (RCFE).
The following items were discussed during our meeting:
  • Facility is seeking to convert SNIF into a RCFE and will continue to operate as a Continuing Care Retirement Center(CCRC). A change in capacity application was received on 10/5/21 and will be process in our regional office (RO).
  • SNIF's current census is 19 residents per administrator. Administrator stated current SNIF residents will transition into RCFE, Facility will not provide care for residents with Prohibited Health Conditions. Facility will ensure appropriate placement will be seek for residents with prohibited health conditions.
  • Facility will provide a packet with all current SNIF residents needs to LPA Flores.
  • Administrator stated a Fire Clearance has been requested by the department and a walk through was conducted on 10/20/21. Department is waiting for granted approval form and will coordinate a visit with Allison Nakatomi for a facility visit.
  • Facility will submitted a hospice waiver request for a maximum of 15 ill resident .Facility currently has a waiver request approval for 1 ill resident. Facility submitted a hospice waiver request on 10/26/21 for a maximum of 6 ill residents, however after clarifying application, facility will resubmit hospice waiver request for a maximum of 15 ill residents and wait for department's approval.
  • A clarification on Care Partners role was provided to the department. Care partners will provide care as caregivers.
  • Facility will submit a job description for Head Nurse to LPA Flores.
Exit interview was conducted with Deborah Herbert, Licensee and a copy of this report was email for signature.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2021
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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