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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191500496
Report Date: 01/23/2024
Date Signed: 01/23/2024 01:28:50 PM

Document Has Been Signed on 01/23/2024 01:28 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: 380DATE:
01/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Joyce FrempongTIME COMPLETED:
01:45 PM
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Licensing Program Analysts (LPA) Elizabeth Irra conducted a subsequent annual inspection visit. LPA met with Joyce Frempong 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 (currently housing 306). The Oak Tree Lodge has a capacity of 70 Residents (private rooms) and is currently housing 55 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 (9) Residents. Total census for this facility is 380.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:
Infection Control: Facility has an Infection Control Plan in place.

Operational Requirements: Facility is adhering to the operational requirements.

Staffing: Facility is adhering to staffing requirements.

Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for Facility Administrator/S-1 through Staff #6 (S-6). Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file. Staff are also trained on Abuse Reporting and Resident Rights.

Refer to LIC 809C for the continuation of this report.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2024
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: MOUNT SAN ANTONIO GARDENS
FACILITY NUMBER: 191500496
VISIT DATE: 01/23/2024
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Resident Records-Incident Reports: LPA reviewed Resident files for Resident #1 (R-1) through Resident #6 (R-6). Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent For Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan, Resident Rights were observed.

Resident Rights-Information: Resident rights are posted and included in Resident files.

Planned Activities: Facility has an Activities Director. Per Administrator, activity schedules are posted.

Disaster Preparedness: The facility has a Disaster Preparedness plan in place.

Residents with Special Health Needs:
Per Administrator, there are no residents with postural supports and no residents with prohibited health conditions. Per Administrator, there are residents utilizing oxygen equipment and there are residents under hospice care. Staff have training for Care of Persons with Dementia.

The following domains remain pending:
· Physical Plant & Environment Safety
· Food Service
· Health Related Services/Incidental Medical Services

Exit interview conducted, copy of appeal rights and a copy of this report was provided to Joyce Frempong.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024
LIC809 (FAS) - (06/04)
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