191222411-2-7-2023-28-AS-MGFS-CNTVKY-20230207153106

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191222411
Report Date: 02/07/2023
Date Signed: 02/07/2023 03:31:25 PM

Document Has Been Signed on 02/07/2023 03:31 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: 41	DATE:	02/07/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:27 AM
MET WITH:	Meagan Swan - Assistant Administrator		TIME COMPLETED:	03:30 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 conducted an unannounced annual visit at the facility with focus on infection control domain, food and medication review. LPA Flores met with Meagan Swan and Nancy Mandic Assistant Administrators 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 conducted a tour of the campus with Meagan Swan and Nancy Mandic Assistant Administrators and observed the following: The Commons/dining area was observed with sufficient sitting area, and social distancing was practice during the visit. A library area with sitting area. Commercial kitchen was observed clean and in good repair. Sufficient food was observed for at least 2 days of perishables and 7 days of non-perishables. A tour of the Hearth was conducted and observed resident(s) room #15 and #2, each room with sufficient lighting, required furniture, and bedding supplies. Bathrooms were observed in each room in working condition, with the required grab bars, and skid strips, water temperature was tested as follow; room #15 tested at 71.0 degrees F. and in #2 tested at 63.1 degrees F. which is not within the required 105-120 degrees F. Facility noticed the issue the night before the visit and has a work order in place. The building has a courtyard with shaded sitting area and a family room with proper signage regarding infection control practices. A tour of the Stewart Cottage was conducted and observed resident(s) rooms #5,11,14,19 with sufficient lighting, bedding supplies, and furniture. Shared shower was observed with grab bars, bathrooms in room #11,14, and 19 were observed with grab bars and in working condition, no skid mats/strips were observed in the bathrooms for room #11, 14, 19 or the shared shower. Proper infection control signage was observed throughout the building. (CONTINUED 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: 02/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023

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: 02/07/2023

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LPA did not tour the Ranch/dementia unit as they are currently in isolation due to COVID 19. The private patio for the Ranch was observed to provide shaded sitting area has a fence water fountain.
The outdoor campus has a fence - lock pool, and two fish ponds that are located in the independent living area. Each building has a fire sprinkle system and smoke/carbon monoxide detectors which are hard wired and interconnected. There are alarms on all exterior doors, and they were tested and operational at the time of visit. The fire extinguishes observed and last maintained on 12/28/22. Administrator certificate was observed for Nancy Mandic #6019341740 exp: 9/8/24. LPA reviewed medication for 5 residents and did not have a 30 day supply for one or more medications per resident.

No deficiencies were cited today.Technical violations and advisories were noted during this visit.

Exit interview was conducted with Meagan Swan Assistant Administrator and a copy of this report and advisories 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: 02/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023

LIC809 (FAS) - (06/04)

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