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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601602
Report Date: 05/24/2023
Date Signed: 05/24/2023 03:12:24 PM


Document Has Been Signed on 05/24/2023 03:12 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:MONTEVISTA GARDENFACILITY NUMBER:
198601602
ADMINISTRATOR:LAURA MARCELA AGUILARFACILITY TYPE:
740
ADDRESS:1812 MONTE VISTA ST.TELEPHONE:
(626) 568-2793
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY:6CENSUS: 4DATE:
05/24/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Laura Aguilar - Administrator TIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst(s) (LPA) Mary Flores conducted a case management visit to follow up on deficiencies found during a complaint investigation on 2/21/23. LPA Flores met with Laura Aguilar Administrator and explained the reason for the visit.

On 2/21/23 LPA Flores conducted an initial complain investigation visit. During this visit LPA Flores reviewed documents for resident #1(R1), during the file review it was found last physician's report for R1 was dated 8/23/21, and an updated needs and care plan was not available for review after initial pre-assessment conducted on 8/30/21.

Per Title 22 Regulations persons with dementia must have a re-appraissal updated annually.

Deficiencies have been noted on LIC 809D per Title 22 Regulations.

Exit interview was conducted with Laura Aguilar Administrator and a copy of this report was provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2023
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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Document Has Been Signed on 05/24/2023 03:12 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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: MONTEVISTA GARDEN
FACILITY NUMBER: 198601602

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/31/2023
Section Cited
CCR
87705(c)(5)

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87705 Care of Persons with Dementia: (c) Licensees who accept and retain residents with dementia shall...:(5) Each resident with dementia shall have an annual medical assessment... and a reappraisal done at least annually,...

This requirement is not met as evidence by:
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Administrator will ensure residents with dementia assessments are updated annually and maintain in files. Administrator will provide a copy of udpated physician's reports and resident appraisal for current residents by POC due date 5/31/23.
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Based on observation, and document review licensee did not ensure physician's report and appraisal assessment were not updated annually which poses a potential risk to the health, safety, personal rights to the persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2023
LIC809 (FAS) - (06/04)
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