191222411-3-11-2022-28-AS-NMAN-CCEUJ7-20220311143704

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191222411
Report Date: 03/11/2022
Date Signed: 03/11/2022 02:37:09 PM

Document Has Been Signed on 03/11/2022 02:37 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
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:	6267966135
CITY:	PASADENA	STATE: CA	ZIP CODE:	91107
CAPACITY:	66	CENSUS: 38	DATE:	03/11/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Administrator Nancy Mandic and Licensee Deborah Herbert		TIME COMPLETED:	02:40 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) Nune Margaryan conducted an unannounced Required One (1) year - Inspection to this facility. Upon arrival, LPA met with Administrator Nancy Mandic and Licensee Deborah Herbert. The purpose of the visit was explained. 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. LPA used the infection control tool to evaluate the facility. LPA inspected the physical plant, COVID-19 procedures, reviewed residents' medications, observed food supply, and reviewed residents and staff files. Facility has submitted a mitigation plan and the plan has been approved.

Facility is a campus area with different cottage buildings which are identify as the Ranch House, The Hearth and The Stewart Cottage. Each building has a fire sprinkle system and smoke detectors which are hard wired and interconnected (w/back-up battery) and were observed in the hallways and bedrooms. There are alarms on all exterior doors, and they were tested and operational at the time of visit. The fire extinguishes observed to be fully charged and meets regulations.

A large body of water / pool area was observed at the facility which was gated and locked. All indoor and outdoor passageways are free of obstruction. Facility has several visiting areas indoor and outdoor. Outdoor areas are covered and have tables and chairs to accommodate the residents during visitations and outdoor activities. One entrance being utilized for each building at the facility, all required posters were posted at the entrance. Screening area is located in the entrance. Sign in sheet, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing mask during this visit.

Continue 809C

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

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: 03/11/2022

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
26
27
28
29
30
31
32

The resident’s bedrooms were inspected. All bedrooms were furnished with required furniture. Residents and common bathrooms are clean and operational w/grab bars and non-skid surface/mats in place. The hot water temperature was tested throughout the facility and measured within Title 22 Regulation guidelines.

Common areas such as the living rooms, dining rooms, hallways, activity rooms, were inspected. All areas were clean and had the required furniture.

Facility has one industrial kitchen and 2 serving kitchens. The industrial kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of 2 days of perishables 7 days of non-perishables. All chemicals and cleaning supplies locked in the storage areas.

LPA observed the centrally stored medication areas to be locked and inaccessible to residents. The first aid kit was observed and found to be in compliance with the Title 22 Regulations.

LPA reviewed 4 residents and 4 staff records. Residents' records were found to be complete and current. Staff files were reviewed, and documentation noted that facility staff maintain a criminal record clearance and associated to the facility. LPA randomly chose some residents' medications to review. Medications are documented properly and stored appropriately.

Based on California Code of Regulations, Title 22, there were no deficiencies observed during the visit. A copy of the report was provided to the Administrator.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022

LIC809 (FAS) - (06/04)

Page: 2 of 2