198603383-9-15-2023-28-AS-ALOZ-CVPV85-20230915161210

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603383
Report Date: 09/15/2023
Date Signed: 09/15/2023 04:12:59 PM

Document Has Been Signed on 09/15/2023 04:12 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:	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: 37	DATE:	09/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:27 AM
MET WITH:	Vicky Torres, Administrator		TIME COMPLETED:	04:27 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) Alberto Lopez conducted the required annual inspection. LPA arrived unannounced and met with Receptionist/Activity Director Liz Gaggos who allowed entry. Administrator Vicky Torres arrived a short time later and assisted with the inspection today. The facility is licensed for 60 residents ages 60 and over. The fire clearance is approved for 60 ambulatory residents. Last Fire Drill was 09/05/2023 There is a hospice waiver approved for 20 residents. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting residents with medications. Disposals of trash are done immediately after changing a resident. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan posted by the entrance. Operational Requirements: The facility has plan to accept or retain clients with dementia. There are currently 0 bedridden residents and 37 non ambulatory residents residing at the facility. The facility has enough liability insurance covering injury to residents and guest. Physical Plant & Environment Safety: 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 and were tested during the visit. Smoke detectors were observed in common areas and in each resident bedroom. There are fire extinguishers throughout the building. 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. LPA inspected 7 random resident rooms, and all had the required furnishings and ample room for storage. There is a combination of private rooms and shared rooms. 1 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 110.0 – 114.8 which is within range.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023

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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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: 09/15/2023

NARRATIVE

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Staffing: There appears to be sufficient staffing at the facility. The administrator’s Vicky Torres certificate expired 7/24/2023. Administrator certificate renewal is in process. Staff employed are all over the age of 18.

Personnel Records-Training: Staff files are maintained at the facility. Staff have current CPR/first aid training and evidence of on-going training.

Resident Records-Incident Reports: Resident files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. One resident file needs to be updated.
Resident Rights-Information: The Complaint poster and Residents personal rights are posted by the main entry. Visiting hours were posted during visit.
Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability.
Food Service: There are sufficient food supplies of 2-day perishable, but facility needs to purchase additional non-perishable items sufficient for 7 days. The food is properly stored in the refrigerator to avoid cross contamination.
Incidental Medical & Dental: The medications are centrally stored and in their original containers. During the visit today, LPA reviewed 6 residents' medication files and observed some PRN to not have labels attached to bottles.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites.
Residents with Special Health Needs: The facility accepts and retains residents with dementia and/or hospice. The staff received training on appropriately caring for residents with dementia, those on hospice, and receiving oxygen. No Smoking - Oxygen in use signs are posted on the doors of residents using oxygen.

Deficiency sited (See 809D) and technical advisories was also provided. An exit interview was held. A copy of this report, LIC809D, technical advisory notes, and appeal rights were given to Adminstrator Vicky Torres.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023

LIC809 (FAS) - (06/04)

Page: 2 of 5

Document Has Been Signed on 09/15/2023 04:12 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: TERRACES AT VIA VERDE-A MEMORY CARE COMMUNITY, THE	FACILITY NUMBER: 198603383
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(26)

General Food Service Requirements

(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. Facility did not have enough 7 day Non perishable food which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/18/2023
	Plan of Correction
1 2 3 4	Administrator agreed to purchase Non perishable food for 7 days and send proof to LPA by POC day.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023

LIC809 (FAS) - (06/04)

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