191222411-11-7-2024-28-AS-MGFS-DASUBE-20241107142613

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191222411
Report Date: 11/07/2024
Date Signed: 11/07/2024 02:26:30 PM

Document Has Been Signed on 11/07/2024 02:26 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/ DIRECTOR:	DEBORAH A HERBERT		FACILITY TYPE:	741
ADDRESS:	2889 SAN PASQUAL STREET		TELEPHONE:	(626) 796-6135
CITY:	PASADENA	STATE: CA	ZIP CODE:	91107
CAPACITY: 66	TOTAL ENROLLED CHILDREN: 0	CENSUS: 51	DATE:	11/07/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:47 AM
MET WITH:	Meagan Swan - Assistant Administrator		TIME VISIT/ INSPECTION COMPLETED:	02:45 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 conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Meagan Swan 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), a kitchen and dining area in the Commons building. LPA Flores conducted a tour with Meagan Swan and observed the following: The Commons - is composed of a library area, mail room, offices, dining room, an outdoor dining area and commercial kitchen. The building is in good repair and each area is properly furnished. The kitchen was observed clean with refrigerators, freezers, and walking pantry which store at least 2 days of perishables and 7 days of non-perishables. The Hearth - is composed of different studio resident rooms with private bathrooms, an activity room, and a medication room. Activity room was observed furnished and fireplace was covered. Three rooms were observed with sufficient lighting, furniture, and bedding supplies. Bathrooms were observed in good repair, each with skid mats, and grab bars, and water temperature was tested between 109.2 - 114.5 degrees F. Stewart - is composed of resident rooms some with half bathrooms and some with full bathrooms. A dining/activity room, two family rooms, a shower room, a medication room, and a few offices. Three rooms were observed with sufficient lighting, the required furniture and bedding supplies. Bathrooms in each room were observed in working condition with grab bars. Rooms #12 and #18 did not have skid mats/strips. Water temperature was tested between 80.9 - 105.8 degrees F. The Ranch (dementia unit) - is composed of resident bedrooms with private bathrooms, a kitchenette, a living/dining room area, a medication room, and a fenced outdoor patio. (CONTINUED ON LIC 809C)

Tony Vasallo	TELEPHONE: (818) 419-8131
Mary G Flores	TELEPHONE: (323) 981-3965
	DATE: 11/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024

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 7

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: 11/07/2024

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

Each exit has a delay egress system. Kitchenette was observed clean, under sink cabinet was observed to store chemicals and was unlocked at the time of the visit. Two rooms were observed with sufficient lighting, furniture, and bedding supplies. Water temperature was tested between 103.0 - 107.6 degrees F.
Water temperature in room #12 in Stewart cottage was tested at 80.9 degrees F., which is not within the required 105-120 degrees F.

Fire sprinkle system is installed in each building and are in working condition. Fire extinguishers were observed. Residents' beds that were observed with bed rails have a bed rail request on file. Garden walk area outside the Commons has two fish/turtle ponds that are wired across and less than 2 ft in depth. Community's pool has a 5ft fence. At around 1:15pm LPA observed Resident #6(R6) using a merry walker at the facility and no postural support physician's request was noted by a physician.

Files and medication was checked for 5 residents. Hospice file was observed for one resident. Five (5) staff files were reviewed. Staff #3(S3) does not have 20 hours of training within the last 12 months. Administrator certificate was observed for Deborah Herbert #6003728740 exp. date: 5/2/25. At least one staff during each shift has a current First Aid/CPR training certificate.

Infection Control and Emergency disaster plans were reviewed and have been reviewed/updated within the last 12 months.

Exit interview was conducted with Meagan Swan 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: 11/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024

LIC809 (FAS) - (06/04)

Page: 2 of 7

Document Has Been Signed on 11/07/2024 02:26 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: 11/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

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. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked. 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 supplies in dementia unit's kitchenette was observed unlocked which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/08/2024
	Plan of Correction
1 2 3 4	Administrator will ensure locks in dementia unit's kitchenette's are repaired and will provide in-service training to staff to ensure they maintain cleaning solutions and dangerous items lock and inaccessible to the residents at all times by POC due date 11/8/24.

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.

Tony Vasallo	TELEPHONE: (818) 419-8131
Mary G Flores	TELEPHONE: (323) 981-3965
	DATE: 11/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024

LIC809 (FAS) - (06/04)

Page: 3 of 7

Document Has Been Signed on 11/07/2024 02:26 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: 11/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). 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 water temperature tested in room #12 at steward cottage tested at 80.9 degrees F., which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/14/2024
	Plan of Correction
1 2 3 4	Administrator will ensure water temperature is adjusted and tests between the required 105-120 degrees F., at all times, and will submit a water temperature log to the department by POC due date 11/14/24.

Section Cited

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 2 out of 3 rooms observed in stewart cottage did not have skid mat/strips in the showers in rooms #12 and #18 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/14/2024
	Plan of Correction
1 2 3 4	Administrator will ensure skid mats/strips are place in room #12 and #18 as well as in each resident's shower and will submit a picture to the department by POC due date 11/14/24.

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

Tony Vasallo	TELEPHONE: (818) 419-8131
Mary G Flores	TELEPHONE: (323) 981-3965
	DATE: 11/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024

LIC809 (FAS) - (06/04)

Page: 4 of 7

Document Has Been Signed on 11/07/2024 02:26 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: 11/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Postural Supports

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. 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 R6 was observed with a merry walker and a physician's order was not observed which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/14/2024
	Plan of Correction
1 2 3 4	Assistant administrator removed the merry walker during the visit and will provide training to staff regarding using postural support to staff a copy of training and an understanding of additional licensing requirements will be submitted to the department by POC due date 11/14/24.

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.

Tony Vasallo	TELEPHONE: (818) 419-8131
Mary G Flores	TELEPHONE: (323) 981-3965
	DATE: 11/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024

LIC809 (FAS) - (06/04)

Page: 5 of 7