191222411-11-15-2021-28-AS-MGFS-C8SSEN-20211115124900

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191222411
Report Date: 11/15/2021
Date Signed: 11/15/2021 12:49:09 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 HOMES		FACILITY NUMBER:	191222411
ADMINISTRATOR:	DEBORAH A HERBERT		FACILITY TYPE:	741
ADDRESS:	2889 SAN PASQUAL STREET		TELEPHONE:	(626) 796-6135
CITY:	PASADENA	STATE: CA	ZIP CODE:	91107
CAPACITY:	26	CENSUS: 41	DATE:	11/15/2021
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	09:07 AM
MET WITH:	Deborah Herbert - Licensee		TIME COMPLETED:	01:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst(s) (LPA) Mary Flores and Jewel Baptiste conducted a case management visit to follow up on capacity increase in which the current Skill Nursing Facility (SNF) building is turning into a residential care for the elderly (RCFE). Licensee submitted LIC 200 for an increase in capacity on 10/7/21. Facility has been approved by the Fire Department to serve a total of 66 residents over 59 years old of which 26 may be non-ambulatory and 40 may be bedridden on 10/25/21. Facility is a campus area with different cottage buildings which are identify as the ranch - dementia unit, the heart - RCFE, and the Stewart - SNF. Facility has a fire sprinkle system in each building. A large body of water was observed in the independent living area and it is not part of the 3 cottages. The Steward Cottage consist of 3 common rooms, and 21 rooms. LPAs observed the following: Activity/dining area, visitors room - room#2 and visitors lounge, and bedrooms #1,2,3,4,5,6,7,8,9,10,12,15, 16,17,18, 19,20,21, all in good condition. Residents rooms have a hospital bed with bed rails, all the required furniture, lighting, and bedding. Each bedroom has a full bathroom except for rooms #1,3,4,5,6, and 7, which do not have a shower. The facility has a common shower across room #4. All bathrooms have the required grab bars and skid strips. Water temperature was tested in rooms #4,10, and 18 and visitors room (#2)and tested between 111.2 and 114.8 degrees F, which is within the required temperature of 105 to 120 degrees F. Fire extinguishers were located in each hall, medication carts were observed in the hallways and were maintained locked, chemicals and cleaning supplies locked in the storage areas. Facility has an industrial kitchen located in the Commons. LPAs observed at least 7 days of non-perishable and at least 2 days of perishable food supplies which include a variety; vegetables, fruits, and pastas .Refrigerator's temperature was observed at 40 degrees and freezer at 9 degrees per staff freezer has a defrosting cycle and temperature log showed temperature was at 0 degrees at 5:30am. (CONTINUED LIC 809C)

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 HOMES	FACILITY NUMBER: 191222411
	VISIT DATE: 11/15/2021

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Facility is following COVID 19 recommendations; such as local central entry and screening upon arrival for visitors, staff, and residents; screening logs were observed. Infection control signs were observed through out the facility. Hand washing signs were added to the common bathrooms and hand washing sinks. Trash cans are covered to allow proper disposal of waste. LPAs observed PPEs supplies sufficient for 30 days.

Medication was reviewed for resident #1, and #2 and a resident file mock was reviewed. LPAs reviewed physician's request for all current SNF residents to transition into RCFE, and physician's order for bed rails.

No deficiencies were observed during this visit. Facility's physical plant follows Title 22 Regulations.

Exit interview was conducted with Deborah Herbert and a copy of this report was provided.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2021

LIC809 (FAS) - (06/04)

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