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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608908
Report Date: 01/08/2023
Date Signed: 01/09/2023 07:40:27 AM


Document Has Been Signed on 01/09/2023 07:40 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:MONTECEDROFACILITY NUMBER:
197608908
ADMINISTRATOR:DAVID WEIDERTFACILITY TYPE:
741
ADDRESS:2212 EL MOLINOTELEPHONE:
(626) 788-4900
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY:300CENSUS: 202DATE:
01/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:06 AM
MET WITH:Ruzanna Sergeyev - Health Services DirectorTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced Required 1-year infection control inspection to this facility. LPA initially met with the Katricia Ravanzo LVN, and explained purpose of the visit. Health Services Director Ruzanna Sergeyev arrived shortly.

At 10:20 AM, with the assistance of the Health Services Director and Welness Manager Talynne Henderson, LPA conducted a tour of the facility inside and out.

There are two (2) entrances being utilized at the facility, the main entrance at the front of the main building and at the back near the Memory Care Unit. There are required poster posted at the entrance doors. Screening area is located in the reception area. Electronic sign in, hand sanitizer and masks are available. LPA was screened upon entry. All staff were observed to be wearing mask upon entrance and during visit.

The facility had submitted and approved Mitigation Plan and Infection Control Plan.

Signs to wear a mask and other COVID-19 prevention protocol signs were posted outside the entrance door. Hand washing, coughing etiquette, physical distancing and other necessary signage were posted in the bathroom and all over the facility. The facility has a designated visitor's area in the front of the main building. The facility has sufficient stock of PPE in the storage room

The facility consists of four (4) buildings. The Independent Living section of the includes floors 1 through 4 of the main building and three (3) separate multi storey Villas named Marsten, Green and Hunt. The facility is fire cleared for 300 non-ambulatory residents, 206 of which maybe bedridden. Hospice waiver for 20 residents.

(continued to LIC 809-C)
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:
DATE: 01/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: MONTECEDRO
FACILITY NUMBER: 197608908
VISIT DATE: 01/08/2023
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(continued from LIC 809)

The independent living units have their own laundry, kitchen, bathrooms, living rooms and dining area. There is a separate beauty salon on the first floor. Other common areas such as two (2) restaurants, Theater, Auditorium, Exercise room, Art Studio, Library and Card Room were observed to be appropriately furnished, clean and in proper order. Multiple activity rooms and a Bar is also available to the independent residents. The Kitchen was observed to be clean and have functioning appliances and fixtures. There is a swimming pool and a spa in the facility and was observed to be appropriately fenced and the gate was observed to be locked, independent residents are given key cards for access to the pool and spa. There is also fountain located at the Independent living yard that is gated with large stones and only allows three (3) inches of water on the surface.

The facility maintains a comfortable temperature at 78°F. The facility's smoke alarms are hard wired and interconnected and back up and tests are done in house on a regular basis. The facility is equipped with sprinkler system which was last tested on December last year. Fire extinguishers are located all throughout the facility and were last serviced on 05/09/22. Fire Drill was last conducted on 12/03/22.

Personal accommodations in resident bedrooms and bathrooms were observed for safety, privacy, and comfort. Random resident rooms were inspected and observed with all required furnishings, working signal system, grab bars and nonskid surfaces in the bathrooms. Hot water temperature in random resident bathrooms were checked and measured a range of 109.2°F to 118.2°F.

At 1:10 PM, LPA reviewed records of ten (10) random residents and eight (8) staff. Resident and staff records appeared to be complete and updated.

Medications were observed to be in the medication cart in the Wellness center. Medication were locked and inaccessible to residents. There were two ( 2) complete first aid kits.

Exit interview conducted. Copy of this report issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2023
LIC809 (FAS) - (06/04)
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