191222411-10-13-2025-28-AS-CDCN-DMEUSL-20251013155030

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191222411
Report Date: 10/13/2025
Date Signed: 10/13/2025 03:51:36 PM

Document Has Been Signed on 10/13/2025 03:51 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
MONTEREY PARK ASC, 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		CENSUS: 51	DATE:	10/13/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:15 AM
MET WITH:	Nancy Mandic, Director of Life Enrichment		TIME VISIT/ INSPECTION COMPLETED:	04:00 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 (LPA) Cynthia Chan conducted an unannounced annual inspection on 10/13/25 using the Compliance and Regulatory Enforcement (CARE) tools. LPA met with Staff, Nancy Mandic, who provided the tour of the facility. The assistant administrator, Meagan Swan, arrived later to assist with the rest of the inspection. The facility is licensed to serve 66 residents, of which (26) may be non-ambulatory and (40) bedridden. There is a hospice waiver approved for (15) residents. The licensed part of the campus consists of (3) cottages called The Hearth, Stewart Cottage, and The Ranch House (Memory Care unit). The Commons building consists of the dining area and kitchen. The liability insurance is maintained at a $1 million for each occurrence and $3 million in total general aggregate. LPA observed the following during the visit today: The Commons building is comprised of a library area, mail room, business offices, dining room, an outdoor dining area, and a commercial kitchen. The food preparation areas were clean. There was adequate supplies of both perishables and nonperishable items. The cleaning supplies are kept in away from the food area. The Hearth building is comprised of resident rooms, activity room, a laundry room, and the medication room. LPA selected (3) rooms (rooms #8, #13, and #15) to inspect. The bathrooms have skid mats, grab bars, and the water temperature was within the required range. Stewart Cottage is comprised of resident rooms, activity room, two family rooms, a shower room, medication room, and a few offices. LPA selected (3) rooms (rooms #4, #7, #12) to inspect. The bathrooms have skid mats and the water temperature was measured within range.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MONTE VISTA GROVE HOMES	FACILITY NUMBER: 191222411
	VISIT DATE: 10/13/2025

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The Ranch House (Memory Care unit) is comprised of resident bedrooms, a kitchenette, a library room, a living/dining room area, medication room, and an enclosed outdoor patio. This building has a delayed egress system. The rooms are clean and have sufficient lighting. The hot water was measured within the required range.

Each building has a fire sprinkle system installed. Carbon monoxide detectors and fire extinguishers were also observed. The outdoor center area has a pond that is less than 2 ft in depth and is protected with wires. The swimming pool is surrounded by a 5ft fence.

LPA selected (7) resident files for review. Each of the files has the admission agreement, consent forms, medical assessment with TB test results, resident's reappraisal plan, and the property valuable form. The medications for these residents were also reviewed and no discrepancies were found. LPA reviewed (5) staff files. Staff have the required documents such as the personnel record, health screening and TB results, first aid training and CPR certificates. Administrator's (Deborah Herbert) certificate expires on 5/2/27. Staff are receiving annual training on dementia care and medication. The Emergency Disaster Plan is reviewed annually and disaster drills are conducted at least monthly for all shifts.

No deficiencies were issued today. Exit interview was conducted with Meagan Swan and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2025

LIC809 (FAS) - (06/04)

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