197605591-5-19-2021-28-AS-JKAN-C35UAM-20210518152456

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197605591
Report Date: 05/18/2021
Date Signed: 05/19/2021 10:41:25 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	WESTMINSTER GARDENS		FACILITY NUMBER:	197605591
ADMINISTRATOR:	WALPER, MICHAEL		FACILITY TYPE:	741
ADDRESS:	1420 SANTO DOMINGO AVENUE		TELEPHONE:	(626) 358-2569
CITY:	DUARTE	STATE: CA	ZIP CODE:	91010
CAPACITY:	200	CENSUS: 144	DATE:	05/18/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Mike Carrasco / Business Office Director Health Services Administrator / Andrew Smith		TIME COMPLETED:	03:45 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 Analysts (LPAs) Joe Katrdzhyan and Nina Galarza conducted a site visit for the Required - 1 Year inspection. Upon arriving at the facility, LPAs met with Mike Carrasco / Business Office Director and were later joined by the Health Services Administrator / Andrew Smith and Director of Wellness / Sev Tienda, who assisted with the visit. The facility is licensed to serve for a capacity of two hundred (200) Non-ambulatory residents ages 60 and above. The facility has an approved Hospice Waiver on file for six (6) residents. The facility also has an approved Dementia Care plan as part of their operation. This is a Continuing Care Retirement Community (CCRC) which includes two separate levels of care; Independent Living and Assisted Living. The Assisted Living residents are located in the Memorial Lodge (ML) and Shu Lodge (SL). Memory Care residents are located in the Hacienda Building. There are currently 26 residents residing in Assisted Living, 7 residents in Memory and 111 residents in Independent Living. There are zero (0) residents receiving hospice services. The facility does NOT have a bedridden fire clearance. During today's visit, LPAs used the infection control domain to complete the Required - 1 Year inspection. Also, the physical plant was toured, medications and food supplies reviewed. LPAs toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. During the tour, LPAs were accompanied by Mr. Smith and Mr. Tienda. LPA toured a random selection of resident rooms. Resident rooms were furnished appropriately. Each resident room has their own bathroom. The bathrooms were observed to be clean and operational w/grab bars. The hot water temperature was tested throughout the facility. The facility has central air and heating accommodations. The front grounds of the facility are well landscaped and have a leveled walkway to the entrance. The outdoor area was enclosed. There are various yard areas throughout the facility that are equipped with patio furniture for resident comfort and safety. (Please see LIC 809C for Additional information)

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2021

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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: WESTMINSTER GARDENS	FACILITY NUMBER: 197605591
	VISIT DATE: 05/18/2021

NARRATIVE

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Facility has a working landline. The kitchen was observed. There was a sufficient amount of perishable and non-perishable food supplies. No pesticides or poisons were stored in the food areas. Medications are centrally stored and locked in each of the lodges/buildings stated on this report. All required information (COVID-19, Emergency Exiting Floor Plan, Personal Rights, Ombudsman information, Theft and loss policy and Emergency Telephone Numbers) are posted in the facility.

The following deficiencies were observed during today's visit;

At 10AM, the hot water temperature in room #10, located in the Shu Lodge was measured at 122.8 degrees F.
At 10:50AM, LPAs observed both exit gates located in the Hacienda building were locked with a padlock and an automatic latch preventing residents from exiting the facility (through the back) in case of an emergency.
At 10:50AM, LPAs observed the self closing mechanism/latches on both exit gates in the Hacienda Building were in disrepair as both gates would not self-close.
At 10:55AM, LPAs observed the delay egress devices on both exit gates located in the Hacienda building were inoperable.

The following deficiencies were observed to be in violation of California code of Regulations, Title 22, Division 6 (refer to 809D)
An exit interview was conducted and a copy of this report was provided to the Health Services Administrator along with the Appeals Rights.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2021

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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: WESTMINSTER GARDENS	FACILITY NUMBER: 197605591
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/18/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation. 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 degree C) and not more than 120 degrees F (49 degree C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	At 10AM, the hot water temperature in room #10, located in the Shu Lodge was measured at 122.8 degrees F. This poses an immediate health and safety concern for the resident in care.
	POC Due Date: 05/18/2021
	Plan of Correction
1 2 3 4	Staff adjusted the hot water temperature in room #10, located in the Shu Lodge and LPA re-tested the hot water temperature and it was measured within Title 22 Regulation guidelines. *Citation was cleared at the time of this visit. No further action is needed*

Type A

Section Cited

CCR

88705(l)(2)

Care of Persons with Dementia. The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: The licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	At 10:50AM, LPAs observed both exit gates located in the Hacienda building were locked with a padlock and an automatic latch preventing residents from exiting the facility (through the back) in case of an emergency. This poses an immediate health and safety concern for the residents in care.
	POC Due Date: 05/18/2021
	Plan of Correction
1 2 3 4	Staff removed the padlocks along with the automatic latch from both exit fence gates located in the Hacienda Building during this visit. Citation was cleared at the time of visit and no further action is needed

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

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2021

LIC809 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: WESTMINSTER GARDENS	FACILITY NUMBER: 197605591
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/18/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(h)

Care of Persons with Dementia. Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	At 10:50AM, LPAs observed the self closing mechanism/latches on both exit gates in the Hacienda Building were in disrepair as both gates would not self-close. This poses an immediate health and safety concern for the residents in care.
	POC Due Date: 05/19/2021
	Plan of Correction
1 2 3 4	The self closing mechanism/latches were repaired on both exit gates making them operable. Citation was cleared at the time of visit and no further action is needed

Type A

Section Cited

CCR

87303(a)

Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	At 10:55AM, LPAs observed the delay egress devices on both exit gates located in the Hacienda building were inoperable. This poses an immediate health and safety concern for the resident in care.
	POC Due Date: 05/19/2021
	Plan of Correction
1 2 3 4	Administrator will have both egress devices repaired making them operable and safe for the residents. Proof of correction must be submitted to CCL by the POC due date.

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

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2021

LIC809 (FAS) - (06/04)

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