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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197605591
Report Date: 08/17/2022
Date Signed: 08/18/2022 10:08:12 AM


Document Has Been Signed on 08/18/2022 10:08 AM - It Cannot Be Edited

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 GARDENSFACILITY NUMBER:
197605591
ADMINISTRATOR:ANDREW M SMITHFACILITY TYPE:
741
ADDRESS:1420 SANTO DOMINGO AVENUETELEPHONE:
(626) 358-2569
CITY:DUARTESTATE: CAZIP CODE:
91010
CAPACITY:200CENSUS: 160DATE:
08/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Director of Wellness / Sev Tienda
Executive Director / Andrew Smith		TIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted a site visit for the Required - 1 Year inspection. Upon arriving at the facility, LPA met with Executive Director / Andrew Smith and was later joined by the 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 24 residents residing in Assisted Living, 9 residents in Memory and 127 residents in Independent Living. The facility does NOT have a bedridden fire clearance. During today's visit, LPA used the infection control domain to complete the Required - 1 Year inspection. Also, the physical plant was toured, medications and food supplies reviewed.

LPA 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, LPA was accompanied by Mr. Tienda and Director of Grounds / Gary Walter.

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 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 resident comfort and safety.

(Please see LIC 809C for additional information)
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 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
VISIT DATE: 08/17/2022
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. During today's walk through, LPA observed COVID-19 prevention/protocol signs posted throughout the facility. LPA reviewed resident medications.

The following concerns were observed during today's visit;
  • At 11:42am, LPA found a scissor in the kitchen cabinet located at the Hacienda Building, left accessible to memory care residents.
  • At 11:50am, LPA tested the delay egress doors (two doors) located inside the Hacienda building and once the doors opened and the alarm sounded off, facility staff were unable to deactivate the noise using the key pad, located by both delay egress doors. The noise sounded off until maintenance had to disconnect the wires.
  • At 12:05pm, LPA discovered that medications Atenolol 50 mg tablet (50 mg by mouth once daily), Losartan 25 mg tablet (25 mg by mouth daily), Simvastatin 10 mg tablet (10 mg by mouth once daily) and Vitamin B-12 1,000 mcg tablet (1,000 mcg by mouth once daily) were missing from the facility and not being administered to Resident 1 (R1), by facility staff, per physician's instructions.

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 along with the Appeals Rights.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/18/2022 10:08 AM - It Cannot Be Edited

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: 08/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/17/2022
Section Cited

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87705 Care of Persons with Dementia. The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
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At 11:42am, LPA found a scissor in the kitchen cabinet located at the Hacienda Building, left accessible to memory care residents. This poses an immediate health and safety concern for the residents in care.
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Type A
08/18/2022
Section Cited

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87303 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:
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At 11:50am, LPA tested the delay egress doors (two doors) located inside the Hacienda building and once the doors opened and the alarm sounded off, facility staff were unable to deactivate the noise using the key pad, located by both delay egress doors. The noise sounded off until maintenance had to disconnect the wires.
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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 HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 08/18/2022 10:08 AM - It Cannot Be Edited

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: 08/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/18/2022
Section Cited

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87465 Incidental Medical and Dental Care.. The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
At 12:05pm, LPA discovered that medications Atenolol 50 mg tablet (50 mg by mouth once daily), Losartan 25 mg tablet (25 mg by mouth
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daily), Simvastatin 10 mg tablet (10 mg by mouth once daily) and Vitamin B-12 1,000 mcg tablet (1,000 mcg by mouth once daily) were missing from the facility and not being administered to Resident 1 (R1), by facility staff, per physician's instructions. This poses an immediate health and safety concern for the resident in care.
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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 HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4