<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197605591
Report Date: 02/09/2024
Date Signed: 02/09/2024 02:55:25 PM


Document Has Been Signed on 02/09/2024 02:55 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
GREATER LA AC/SC, 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: 162DATE:
02/09/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:08 PM
MET WITH:Sev Tienda - Wellness DirectorTIME COMPLETED:
03:15 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) Tena Herrera conducted an unannounced Case Management. LPA met with Sev Tienda and explained the purpose for the visit.

Today's visit is to observe the delayed egress system and the two exit doors that have been approved to remain locked per the Approved Fire Safety Request (STD850) dated 6/1/21. Details on this approval state,"FACILITY IS LICENSED TO SERVE 200. NON-AMBULATORY RESIDENTS AGE 60 AND ABOVE. HOSPICE WAIVER APPROVED FOR 6 RESIDENTS. MEMORY CARE UNIT APPROVED FOR 12 RESIDENTS. FACILITY IS APPROVED TO LOCK BOTH EXTERIOR DOORS ON THE PERIMETER GATES IN THE MEMORY CARE UNIT/ HACIENDA BUILDING", with a special comment by the approving inspector Smith stating "approved to lock/secure 2 exit gates".

There are currently 10 Residents in the Memory Care/Support Unit "Hacienda Building".

Delayed egress system was tested and is working. All walkways around the Memory Care/Support Unit "Hacienda Building" unit were clear of hazards.

The facility has 3 entrance/exits that lead to the front of the Hacienda Building, and 2 exits that lead to the back patio. The gates that will be locked/secured are the metal gates in the exterior of the building that wrap around the back yard/patio area. There is one gate on each side of the building. These gates are secured with a metal or rubber wire and are able to be opened by staff in the case of an emergency.

There were no deficiencies cited on today's visit.

Exit interview and copy of report and license has been provided to Wellness Director Sev Tienda
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena HerreraTELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2024
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 1