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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197605591
Report Date: 04/21/2025
Date Signed: 04/21/2025 04:24:56 PM

Document Has Been Signed on 04/21/2025 04:24 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:WESTMINSTER GARDENSFACILITY NUMBER:
197605591
ADMINISTRATOR/
DIRECTOR:		ANDREW M SMITHFACILITY TYPE:
741
ADDRESS:1420 SANTO DOMINGO AVENUETELEPHONE:
(626) 358-2569
CITY:DUARTESTATE: CAZIP CODE:
91010
CAPACITY: 200TOTAL ENROLLED CHILDREN: 0CENSUS: 146DATE:
04/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:13 AM
MET WITH:Jeremiah Hovsepian Bearce - Executive Director
Eusebio 'Sev' Tienda - Director of Wellness		TIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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 Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit. LPA met with Andrew Villegas, Nurse Supervisor and explained the purpose of the visit. Shortly after, LPA met with Jeremiah Hovsepian Bearce, Executive Director and Eusebio 'Sev' Tienda, Director of Wellness who both assisted LPA with the inspection. The facility is licensed to serve (200) non-ambulatory residents age 60 and above. Hospice waiver approved for (6) residents and Memory Care approved for (12) residents. Facility is approved to lock both exterior doors on the perimeter gates in the Memory Care unit (Hacienda Bldg.). Facility is a Continuing Care Retirement Community (CCRC) which includes separate buildings throughout the premises. The Assisted Living residents are located in the Memorial Lodge (ML) and Shu Lodge (SL). Memory Care Unit which is located in the Hacienda Building, is approved for 12 residents. Currently, there are 29 residents in the Assisted Living, 10 residents in Memory Care and 107 residents in Independent Living.
LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility's Infection Control Plan was recently reviewed and updated on 03/17/2025. Staff are adhering to infection control requirements. The facility allows visitors, such as ombudsman and advocacy representatives to see residents privately at reasonable hours and without prior notice.


Operational Requirements: The Infection Control Plan has been included to the Plan of Operation. Hospice Waiver for 6 is approved and there are (6) residents receiving hospice care, (0) bedridden . A fire clearance is in place. Fire Drill was last conducted on 03/13/2025. Liability Insurance is in place and expires on 01/01/2026.
Physical Plant & Environment Safety: LPA toured the physical plant areas inside and outside and was accompanied by Andrew Villegas, Nurse Supervisor. The facility is a gated community with multiple single story buildings to accommodate Memory Care, Assisted Living and Independent Living residents, all arranged in a campus-like setting. LPA toured a random selection of resident rooms in the Assisted Living (Memorial lodge and Shu lodge) and Memory Care unit (Hacienda bldg.). Resident rooms were furnished appropriately. Each resident room has their own bathroom. The bathrooms were observed to be clean, operational w/grab bars and have slip-resistant mats. The hot water temperature was tested throughout the facility and measured within Title 22 Regulation guidelines. 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. There are various yard areas throughout the facility that are equipped with patio furniture for residents' comfort and safety. There are smoke detectors, carbon monoxide detectors and an emergency sprinkler system throughout the facility are operational and compliant. The fire extinguishers were observed throughout the facility and are fully charged. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. ***CONTINUED ON LIC-809-C***
David SicairosTELEPHONE: (323) 981-3982
Bennette PenaTELEPHONE: (323) 981-3307
DATE: 04/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/21/2025
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: WESTMINSTER GARDENS
FACILITY NUMBER: 197605591
VISIT DATE: 04/21/2025
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Staffing: Facility employs a sufficient number of staff including night staff that are trained and able to provide care and supervision to the residents in the event of an emergency. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility. Personnel Records-Training: LPA reviewed staff files and verified health screenings, criminal records and fingerprint clearances. Personnel files include documentation of staff training in areas like medication assistance, postural supports, Alzheimer’s and Dementia care, health clearance, vaccinations, and 1st Aid/CPR. Administrator, Andrew Smith's certificate is valid and expires on 02/11/2027.
Residents Rights-Information: The required information such as Personal rights of residents, Emergency Exiting Floor Plan, Ombudsman information, Complaint poster, Rights of Resident Councils, Visiting policy, Theft and loss policy and Emergency Telephone Numbers are posted throughout the facility. The facility has resident rights council who meet regularly. The facility provides internet services to all residents and have access to the facility phone.
Planned Activities: The facility provides sufficient space to accommodate both indoor and outdoor activities. The facility offers scheduled activities and an up to date calendar is posted in separate buildings. The facility employs a full-time staff (Activity coordinator) to organize, conduct and evaluate planned activities.
Food Service: Sufficient food supply is stored in the kitchen and food storage room consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Sanitation practices and cleanliness in the kitchen were observed. Some kitchen staff workers were observed to be using hairnets and disposable gloves while working.
Incidental Medical & Dental: Medications are centrally stored and properly labeled in their original containers or bubble packs. Facility has (2) medical carts and uses eMar called point-click care to document residents medications. A complete first aid kit is maintained in the medication room. Memory Care and Assisted Living have their own medication room. LPA reviewed multiple residents medications in the medication room with no issues observed.
Resident Records-Incident Reports: Resident files are maintained in the business office. A total of (10) resident files were reviewed. Resident files contained Admission Agreements, Physician's Reports, Appraisal, TB clearance, Functional Capability Assessment, Physician's Orders, Medical Consent and Medication Records. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers in place. Emergency training such as earthquake drill, elopement and evacuation procedures are conducted on a quarterly basis. Evacuation procedures, including emergency exits are included in the facility sketch.
Residents with Special Health Needs: Facility admits residents with dementia and staff files reviewed today all have required training documented. LPA observed 'no smoking oxygen in use' signs posted in some residents' rooms.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during todays' visit.

Exit interview held and a copy of the report was provided to Director of Wellness Eusebio 'Sev' Tienda.

SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2025
LIC809 (FAS) - (06/04)
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