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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610430
Report Date: 07/03/2023
Date Signed: 07/03/2023 03:15:14 PM


Document Has Been Signed on 07/03/2023 03:15 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:MONTECEDROFACILITY NUMBER:
197610430
ADMINISTRATOR:WEIDERT, DAVIDFACILITY TYPE:
741
ADDRESS:2212 EL MOLINO AVE.TELEPHONE:
(626) 403-5403
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY:300CENSUS: 214DATE:
07/03/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Ruzanna Sergeyev, Kohar KelkeyanTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) MIchael Cava conducted a Prelicensing inspection visit to this facility. This is for a Change in Ownership (CHOW) application. LPA met with the Director of Resident Health Services, Ruzanna Sergeyev and Director of Resident Services, Kohar Kelkeyan and explained to them the purpose of the visit.

At approximately 10:45am, LPA conducted a tour of the facility inside and out. 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 applicant has requested and received a fire clearance for 300 non-ambulatory residents, 206 of which may be bedridden. The applicant also requested a Hospice waiver for 20 residents.

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. Screening area is located in the reception area. Electronic sign in, hand sanitizer and masks are available. The facility has also submitted an approved Infection Control Plan.

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 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 locked. There is also a fountain located at the Independent living yard that is gated.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:
DATE: 07/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2023
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: 197610430
VISIT DATE: 07/03/2023
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The memory care unit has a delayed egress, which was tested. The memory care unit has it's own dining room and activity area, which was observed to be appropriately furnished, clean and in proper order.

The facility maintains a comfortable temperature at 75°F. The facility's smoke alarms and carbon monoxide detectors are dual. They are hard wired and interconnected. The facility is equipped with sprinkler system. Fire extinguishers are located all throughout the facility. The facility was granted their fire clearance on 06/27/23.

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 106.2°F to 110.7°F.

Medications were observed to be in the medication cart in the Wellness center for both the independent living unit and memory care unit. Medication were locked and inaccessible to residents. There is a complete first kit on site.

Pursuant to Title 22, Division 6 of the CA Code of Regulations, the facility's physical environment appears to be compliant and ready for licensure. Centralized Applications Bureau (CAB) will be advised and a copy of this report provided.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2023
LIC809 (FAS) - (06/04)
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