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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603383
Report Date: 07/11/2024
Date Signed: 07/11/2024 03:13:56 PM


Document Has Been Signed on 07/11/2024 03:13 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: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: 37DATE:
07/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:04 AM
MET WITH:Mark ChisumTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted required annual inspection. LPA met with Environmental Director of Services- Mark Chisum and purpose of today’s visit. This facility is licensed to serve sixty (60) non-ambulatory residents and all bedrooms are approved for non-ambulatory. This facility may retain no more than twenty (20) hospice residents. There are six (6) residents under hospice care at this time.
LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected eight (8) resident rooms. All resident bedrooms contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. LPA Ramirez observe postings encouraging proper handwashing etiquette in restrooms. LPA Ramirez observed grab bars near toilets and inside showers. LPA Ramirez observed no-slip mat in showers. The facility is approved for delay egress doors. LPA Ramirez tested and observed doors to be in good repair.

Food Service: LPA Ramirez observed sufficient supply of nonperishables for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0-degree F (-17.7 degree C), and refrigerators with maximum temperature of 40 degree F. (4 degree C).

Planned Activities: Facility has an activities director and LPA Ramirez observed staff conducting seated exercises with residents during physical plant tour.

Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed a facility land line.

Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D) in place. Last documented emergency drills were conducted on 06/26/2024 and 05/23/2024. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. LPA Ramirez observed emergency food supply.


SEE 809-C for continuation of report
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


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: TERRACES AT VIA VERDE-A MEMORY CARE COMMUNITY, THE
FACILITY NUMBER: 198603383
VISIT DATE: 07/11/2024
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Residents with Special Needs: No large bodies of water or pools were observed. LPA Ramirez observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. LPA Ramirez observed several oxygen tanks in resident rooms secured in stands. Knives, sharps, or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Auditory devices and delay egress perimeters were observed to be in working order.

Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication rooms and in bubble packs and/or original containers. The facility uses the Medication Administration Record (MAR) electronic log to document medications given. The facility provides incidental medical services.

Staffing: Administrator Certificate for Robert Jakini expires 07/24/2025. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed required annual training, CPR and First Aid for five (3) out of the five (5) personnel records reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for five (5) out of the five (5) personnel records reviewed.

Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place.



Operational Requirements: The fire clearance is approved for sixty (60) non-ambulatory. This facility may retain no more than twenty (20) hospice residents. There are six (6) residents under hospice care.

Resident Records/Incident Reports: LPA reviewed Resident files for eight (8) residents. Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed.

No deficiencies were cited during this inspection. Exit interview was conducted and a copy of this report was provided via email due to printer problems.

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2