197605591-6-15-2023-28-AS-ACAN-CSTUUA-20230615155309

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197605591
Report Date: 06/15/2023
Date Signed: 06/15/2023 03:55:46 PM

Document Has Been Signed on 06/15/2023 03:55 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	WESTMINSTER GARDENS		FACILITY NUMBER:	197605591
ADMINISTRATOR:	ANDREW M SMITH		FACILITY TYPE:	741
ADDRESS:	1420 SANTO DOMINGO AVENUE		TELEPHONE:	(626) 358-2569
CITY:	DUARTE	STATE: CA	ZIP CODE:	91010
CAPACITY:	200	CENSUS: 163	DATE:	06/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Director of Wellness / Sev Tienda		TIME COMPLETED:	04:00 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 Analyst (LPA) Ashley Calderon conducted an unannounced site visit for the Required - 1 Year inspection, using the CARE Tool. Upon arriving at the facility, LPA met with Director of Wellness Sev Tienda and Health Services Administrator Jose Antonio "Tony" Agoncillo 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. This 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 residents are located in the Hacienda Building. There are currently 32 residents residing in Assisted Living, 9 residents in Memory Care and 122 residents in Independent Living. Two residents on Hospice. LPA toured the physical plant areas inside and outside. LPA toured facility with Sev, Tony and staff Gary Walter/ Building and Grounds staff. Random rooms were selected. LPA in Memorial Lodge toured room 3, 8,16. Memorial Lodge had office room, laundry room, and barber shop locked and inaccessible to residents in care. LPA toured in the Shu Lodge toured rooms 1, 4, activity room, janitor room contains chemicals and disinfectants (locked), and 4 storage closets containing linen, towels and storage supplies inaccessible to clients in care. LPA observed Memory care room 3 and 6, activity room and staff room, building had delayed egress system in place. Resident rooms were furnished appropriately. Each resident room has their own bathroom. The bathrooms were observed to be clean and operational w/grab bars and showers/bathtubs had non skid coating tiles, mats, strips or ridges. The hot water temperature was tested throughout the facility and measured within Title 22 Regulation guidelines. Rooms had emergency call systems in residents bathrooms, and residents had pendants. LPA observed wellness room, medications were maintained locked in medication carts. LPA observed and tested operable carbon monoxide detectors in facility buildings. Pull fire alarms and fire extinguishers (charged and serviced) were located through the facility. Last fire drill conducted on 5/23/23. (Continuation on LIC 809-C...)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 3 of 5

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: 06/15/2023

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
26
27
28
29
30
31
32

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 / shading for resident comfort and safety. LPA observed pond which does not exceed a few inches of water and outdoor grounds were well landscaped.

Facility has a working landline. The kitchen was observed. There was a sufficient amount of perishable and non-perishable food supplies. Food menu observed posted in Morrison House, Online Portal and provided to residents. Activity calendar posted. Sufficient PPE observed. Liability insurance expires on 1/1/2024. Administrator Certificate renewal for Andrew Smith pending, LIC 9214 submitted for renewal. Valerie Garcia Director of Hospitality, Admin. Certificate Expires on 10/12/24.

No deficiencies were observed during today's visit.

Visit will need to be continued due time restraint, interview was conducted and a copy of this report was provided via email at eusebio.tienda@humangood.org (printer issues)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023

LIC809 (FAS) - (06/04)

Page: 5 of 5