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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603383
Report Date: 07/01/2024
Date Signed: 07/01/2024 02:45:16 PM


Document Has Been Signed on 07/01/2024 02:45 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:TERRACES AT VIA VERDE-A MEMORY CARE COMMUNITY, THEFACILITY NUMBER:
198603383
ADMINISTRATOR:JAKINI, ROBERTFACILITY TYPE:
740
ADDRESS:1155 VIA VERDETELEPHONE:
(909) 293-6466
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY:60CENSUS: 36DATE:
07/01/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Robert JakiniTIME COMPLETED:
02:50 PM
NARRATIVE
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During the course of investigation of complaint # 28-AS-20240304141910, a deficiencies were observed and cited per California Code of Regulations, Title 22 and recorded on LIC 809D.
At the time of visit LPA observed that R1's medications were unlocked in R1's room. Also observed scissors, shaving razors and perfumes, deodorants and other hygiene items unlocked in R#1's bathroom cabinet. Per R1's Physicians Report, R#1 is at risk at allowed direct access to personal grooming and hygiene items.


An exit interview was conducted, and a copy of the Report and Appeal Rights were provided to Robert Jakini.





SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune MargaryanTELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2024
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 07/01/2024 02:45 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
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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/02/2024
Section Cited
CCR
87705(f)(2)

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87705 Care of Persons with Dementia. (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:

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Licensee/ Administrator remove all medications during the visit. Additionally, licensee / administrator will conduct an in-service training about this section code with all staff and submit an attendance sheet with staff signatures to CCLD by POC due date.
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Based on observation, the licensee did not comply with the section cited above. LPA observed R#1s medication unlocked in R3!'s room
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Type A
07/02/2024
Section Cited
CCR87705(f)(1)

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87705 Care of Persons with Dementia. (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s)
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Licensee/ Administrator remove scissors, shaving razors during the visit Additionally, licensee / administrator will conduct an in-service training about this section code with all staff and submit an attendance sheet with staff signatures to CCLD by POC due date. Licensee / Administrator will contact to R#1's Pyshician to deternine that R1 not at the risk to keep parfumes in her room.

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LPA observed scissors, shaving razors and perfumes, deodorants and other hygiene items unlocked in R#1's bathroom cabinet. Per R1's Physicians Report, R#1 is at risk at allowed direct access to personal grooming and hygiene items.
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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: Wei Siew HoTELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune MargaryanTELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2024
LIC809 (FAS) - (06/04)
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