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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191500496
Report Date: 12/09/2022
Date Signed: 12/09/2022 01:10:49 PM

Document Has Been Signed on 12/09/2022 01:10 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:MOUNT SAN ANTONIO GARDENSFACILITY NUMBER:
191500496
ADMINISTRATOR:JOYCE FREMPONGFACILITY TYPE:
741
ADDRESS:900 EAST HARRISON AVENUETELEPHONE:
(909) 624-5061
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY: 520CENSUS: 76DATE:
12/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ariana Villapudua/Assistant Director TIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced Required-1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Ariana Villapudua and discussed the purpose of today's visit.

This is a Continuing Care Retirement Community (CCRC) which consists of Assisted Living (Oak Tree Lodge), Memory Care (Taylor Villa), Assisted Living (Harrison Villa) and Independent Living. The Oak Tree Lodge has a capacity of 70 Residents (private rooms) and is currently housing 58 Residents. Taylor Villa has a capacity of (10) Residents (private rooms) and it currently houses (10) Residents. Harrison Villa has a capacity of (10) Residents (private rooms) and currently houses (8) Residents.

The following were observed/inspected: .
  • COVID-19 Infection Control Practices (including signs) were observed at the entrance of this facility and throughout the facility. Signs to promote hand washing, cough/sneeze etiquette, and physical distancing were observed. Signs on putting on and removing PPE supplies were posted in front of Residents bedroom entrance doors.
  • PPE supplies observed.
  • Medication reviewed for Resident #1 through Resident #7 (R-1 through R-7)
  • Per Assistant Director, (75) Residents are fully vaccinated (including boosters) and (1) Resident has both vaccines and not the booster (resident refused the booster). Per Assistant Director, all Staff are fully vaccinated.
  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days observed. Each location has a "satellite kitchen" and there is a main cafeteria on campus as well.
  • Staff responsible for direct care and supervision were observed wearing masks.
Exit interview conducted, a copy of this report and Appeal Rights were provided to Ariana Villapudua. Note; LPA was experiencing technical difficulties during today's visit.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2022
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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