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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197605591
Report Date: 06/16/2023
Date Signed: 06/16/2023 04:13:45 PM


Document Has Been Signed on 06/16/2023 04:13 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 GARDENSFACILITY NUMBER:
197605591
ADMINISTRATOR:ANDREW M SMITHFACILITY TYPE:
741
ADDRESS:1420 SANTO DOMINGO AVENUETELEPHONE:
(626) 358-2569
CITY:DUARTESTATE: CAZIP CODE:
91010
CAPACITY:200CENSUS: 163DATE:
06/16/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Director of Wellness / Sev TiendaTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Ashley Calderon conducted a site visit for the Required - 1 Year inspection, using the CARE Tool. Today's visit is a continuation annual inspection case management. Upon arriving at the facility, LPA met with Director of Wellness Sev Tienda.

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.

On today's visit LPA interviewed 4 staff and 5 residents. LPA along side with Teresita Bastes and Sev Tienda reviewed a total of 5 resident medication and medication administration records and no deficiencies noted.

LPA Calderon along side with Veronica Davila/ Human Resource Director, reviewed a total of 5 staff files, all staff are cleared and appropriate documentation in files.

No deficiencies were observed during today's visit. An exit interview was conducted and a copy of this report was provided to Sev Tienda via email at eusebio.tienda@humangood.org (due to printer issues).
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley CalderonTELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2023
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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