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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603383
Report Date: 08/17/2022
Date Signed: 08/17/2022 12:21:59 PM


Document Has Been Signed on 08/17/2022 12:21 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:HIGGINS, DEBORAHFACILITY TYPE:
740
ADDRESS:1155 VIA VERDETELEPHONE:
(503) 443-1818
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY:60CENSUS: 25DATE:
08/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Administrator, Vicky TorresTIME COMPLETED:
12:35 PM
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Licensing Program Analyst's (LPA's) Vasallo and Yang conducted an annual required visit. LPA's met with Administrator, Vicky Torres and explained the reason for the visit. LPA's used the infection control tool to evaluate the facility. LPA's observed the physical plant, COVID-19 procedures, residents' medications and records, food supply, and staff records. The facility cares for elderly residents and is approved for 20 hospice residents. There are currently 2 residents on hospice.

Resident bedrooms were randomly chosen for inspection. Facility has private and shared rooms. Each room has a bedframe, linen, dresser, light, and sufficient closet space. The resident bathrooms have the required grabs bars and non-skid materials in the shower and near the toilet. The hot water was between 105.3 - 117.1 degrees which is within the required 105 - 120 degrees. The kitchen was inspected. There is a large commercial kitchen which contains sufficient perishable and non-perishable food. All the appliances were clean and operating properly. The refrigerators and freezers were set at the appropriate temperatures. The common areas include the living room, dining room, activity room and outside sitting areas. These areas are clean and have the required furniture. Stairways and exit doors are free of any obstruction. The second floor has the required evacuation chairs in the stairways. There is a screening station at the entrance of the facility which is used to screen visitors and staff. Visitors are required to sign-in. Facility currently has at least a 30-day supply of PPEs.

Six resident records were reviewed to confirm health screenings and emergency contacts are updated. Six staff records were reviewed to confirm health screenings, training and fingerprint clearances. All records were complete. Six residents' medications were reviewed. Medications are documented properly and given as prescribed.

Per California Code of Regulations, Title 22, there were no deficiencies observed during the visit. Exit interview held. A copy of the report was provided.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2022
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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