191222411-11-2-2023-28-AS-MGFS-CX7TSB-20231102145852

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191222411
Report Date: 11/02/2023
Date Signed: 11/02/2023 02:59:13 PM

Document Has Been Signed on 11/02/2023 02:59 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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:	66	CENSUS: 42	DATE:	11/02/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:33 AM
MET WITH:	Nancy Mandic - Director of Resident Services		TIME COMPLETED:	03:15 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 (LPA) Mary Flores and Office Technician (OT) Jade Xu conducted an unannounced annual investigation visit using the CARE inspection tool. LPA met with Nancy Mandic and explained the reason for the visit. Facility is licensed to serve 66 residents over 59 years old of which 26 may be non-ambulatory and 40 may be bedridden. Facility is approved to retain/accept fifteen (15) hospice residents. Facility is a campus area with separate cottage buildings which are identify as the Ranch House (Dementia unit), the Hearth and Stewart Cottage (Assisted Living). LPA, OT, and Nancy Mandic toured the facility and observed the following: The Commons which consist of facility's kitchen, library, and dining area: The kitchen is currently under construction due to plumbing issues which started on September 2023. A temporary trailer kitchen is set up outside the dining area for meal preparation. The trailer has a walking refrigerator and a small freezer which stores food for the 2 days worth of perishables, and the pantry is currently in the administration building which stores 7 days of non-perishables. The dining room and library are clean with sufficient seating area. Upon exiting the building towards the independent living there are two ponds protected by wire over them and a 5ft fenced on the bridge. A fence pool is in the back. The Hearth: Has it's own smaller dining room with a glass screen - fireplace, activities supplies are stored and accessible to resident. Three (3) private bedrooms were observed each have sufficient lighting, furniture, and bedding supplies. Bedroom #3 does not have a bed per residents choice. Bathrooms were observed in working condition, with skid mats/grab bars, and water temperature was tested between 102.7 - 108.6 degrees F., which is not within the required 105-120 degrees F. The Ranch House (Dementia Unit): Has a kitchenette with a small refrigerator for snacks. Drawer was observed with a lock unlock during the visit with a pair of large scissors, and cleaning solution bottle was accessible to the residents next to the microwave. Medication room was locked.(CONTINUED ON LIC 809C)

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MONTE VISTA GROVE HOMES	FACILITY NUMBER: 191222411
	VISIT DATE: 11/02/2023

NARRATIVE

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Egress system is in working condition, the building has a fenced patio for outdoor activities with shaded seating area. Dining room is clean and in good repair. Three (3) bedrooms were observed; each room has sufficient furniture, bedding supplies, and lighting. Beds in rooms #3, and #6A were observed to have half bed rails, and bed in room #7B was observed to have a half and a attached rail which make a full bed rail. No physician's request on file for bed rails. Bathroom were observed clean and in working condition, water temperature was tested between 106.1 - 112.1 degrees F. which is within the required 105-120 degrees F.

The Steward: It's currently under remodeling which was notified to the department in 2022. It has a clinical room, 3 offices, a medication room, the nurse station has been remove and it will be turn into a seating area. Dining area and kitchenette to prepare snacks. Two (2) bedrooms were observed, both with sufficient lighting, furniture, and bedding supplies. Beds in both rooms have half bed rails. No physician's request on file for bed rails. Room #6 has a half bathroom and room #14 has a full bathroom, both are in working condition, with grab bars, skid was not observed, and water temperature was tested between 109.5 - 109.9 degrees F. A common shower was observed with grab bars, no skid mat was observed.

LPA observed construction on the parking lot in front of the The Commons, the Hearth, and the Ranch. Caution tape is placed. Permits were reviewed. This was not notify to the department as of 11/2/23.

Fire sprinkle system was observed throughout the buildings. Fire extinguishers were observed throughout and last checked on 12/25/22. Last emergency drill was conducted on 10/18/23.

Medication was reviewed for 6 residents. Files were reviewed for 5 residents and 5 staff. Administrator certificate was observed for Deborah Herbert #6003728740 exp. date: 5/2/25. Interviews were conducted with 3 staff and 3 residents.

Exit interview was conducted with Deborah Herbert and a copy of this report, LIC 809D, and appeal rights were provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/02/2023 02:59 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MONTE VISTA GROVE HOMES	FACILITY NUMBER: 191222411
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in cleaning solution was observed in the dementia unit next to the microwave, and scissors were observed in a drawer that was unlocked which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/03/2023
	Plan of Correction
1 2 3 4	Administrator will provide in-service training to staff regarding the section above which will be schedule by POC due 11/3/23 and a copy of signing sheet, duration of training, and topic will be submitted by 11/9/23. Cleaning solution and drawer was locked at the time of the visit.

Type A

Section Cited

CCR

87608(a)(5)(A)

Postural Supports

(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in 4 out of 5 residents have half bed rails in their beds which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/03/2023
	Plan of Correction
1 2 3 4	Administrator will request a physician request for half bed rails and submit a copy to the department by POC due date 11/3/23.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

LIC809 (FAS) - (06/04)

Page: 3 of 7

Document Has Been Signed on 11/02/2023 02:59 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MONTE VISTA GROVE HOMES	FACILITY NUMBER: 191222411
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87608(a)(5)(B)

Postural Supports

(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in 1 out of 5 residents has a half and an additional rail making a full length rail for R1 which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/03/2023
	Plan of Correction
1 2 3 4	Administrator will discuss with family of either requesting a half bed rail request from the physician or placing resident in hospice to provide a full length bed rail andn will submit a copy of physician's bed rail request to the department by POC due date 11/3/23.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

LIC809 (FAS) - (06/04)

Page: 4 of 7

Document Has Been Signed on 11/02/2023 02:59 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MONTE VISTA GROVE HOMES	FACILITY NUMBER: 191222411
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(e)(5)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in showers observed in the steward cottage, common shower and shower in room #14 do not have skid mat or strips which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/09/2023
	Plan of Correction
1 2 3 4	Administrator will provide skid mat or strips in each shower in the steward cottage and will submit pictures of common shower and shower in room #14 by POC due date 11/9/23.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

LIC809 (FAS) - (06/04)

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