198603383-7-29-2021-28-AS-TVAO-C5DS2J-20210729132937

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603383
Report Date: 07/29/2021
Date Signed: 07/29/2021 01:29:49 PM

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:	TERRACES AT VIA VERDE-A MEMORY CARE COMMUNITY, THE		FACILITY NUMBER:	198603383
ADMINISTRATOR:	HIGGINS, DEBORAH		FACILITY TYPE:	740
ADDRESS:	1155 VIA VERDE		TELEPHONE:	(503) 443-1818
CITY:	SAN DIMAS	STATE: CA	ZIP CODE:	91773
CAPACITY:	60	CENSUS: 0	DATE:	07/29/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Applicant, Nikolas Kavayiotidis and Administrator, Vicky Torres.		TIME COMPLETED:	01:45 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) Tony Vasallo, Nune Margaryan, and Nina Galarza conducted a prelicensing visit. LPA’s met with applicant, Nikolas Kavayiotidis and administrator, Vicky Torres. The applicant is a current licensee and therefore a component III is not required. The building is a new construction and therefore has never been licensed. The fire clearance has been approved for 60 non-ambulatory residents. The applicant has requested to care for dementia residents. A hospice waiver has been requested for 20 hospice residents. The physical plant was toured with the applicant and administrator. The following was observed. The physical plant consists of a lobby, conference rooms, lounge, activity room, dining room, salon, kitchen, kitchenette, laundry room, staff lounge, medication room/nurse’s room, 2 elevators, and outdoor courtyard. The building has 2 floors. The building has delayed egress devices on exit doors to alert when dementia residents exit. Smoke detectors were observed in common areas and in each resident bedroom. There are fire extinguishers throughout the building. There are 2 medication rooms/nurse rooms, 1 located on each floor. There are complete first aid kits in the medication rooms. Windows and doors are in good condition and there were no obstructions near doors. Windows do not have security bars. There are 43 bedrooms and 31 bathrooms. There is a combination of private rooms and shared rooms. 3 of the resident rooms were modeled to show shared and private furniture layout. All the bedrooms have sufficient closet space and lighting. The bathrooms in resident rooms have the required grab bars and non-skid materials in the showers. The hot water was tested in multiple bathrooms and was between 108.5 – 114.1. The building also has 6 public bathrooms which also have grab bars for residents. The call light system was tested in the bedrooms and bathrooms and was functioning at the time of the visit. Room #223 did not have running water due to repairs in another area of the building. Applicant indicated residents will not reside there until the water has been repaired. Continued on 809C.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021

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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: TERRACES AT VIA VERDE-A MEMORY CARE COMMUNITY, THE	FACILITY NUMBER: 198603383
	VISIT DATE: 07/29/2021

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The kitchen was inspected. The walk-in refrigerator was not operating at the time of the visit. Facility has other refrigerators and large freezers to store perishable food. There was sufficient non-perishable food in the pantry. The kitchen has sufficient plates and silverware. Cleaning supplies and chemicals will be stored in the janitor’s closet. There is a dining room on the 1^st and 2^nd floor with adequate space for multiple residents and sufficient sitting area. The courtyard has a small water fountain on top of a planter which does not pose a danger to residents. There is adequate patio furniture and lighting. There is also an enclosed walking path on the side of the building. This side of the building also has delayed egress devices since it leads to the street. There are no large bodies of water that pose a danger to residents.

Based on LPA’s observations, the facility meets Title 22 Regulations.

Exit interview held. A copy of the report was provided to applicant.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021

LIC809 (FAS) - (06/04)

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