374604441-1-12-2024-08-AS-AROS-CZF3EW-20240112171150

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604441
Report Date: 01/12/2024
Date Signed: 01/12/2024 05:11:58 PM

Document Has Been Signed on 01/12/2024 05:11 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	MONTE VISTA VILLAGE SENIOR LIVING		FACILITY NUMBER:	374604441
ADMINISTRATOR:	ADRIAN GUILLEN		FACILITY TYPE:	740
ADDRESS:	2211 MASSACHUSETTS AVENUE		TELEPHONE:	(619) 465-1331
CITY:	LEMON GROVE	STATE: CA	ZIP CODE:	91945
CAPACITY:	219	CENSUS: 121	DATE:	01/12/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:48 PM
MET WITH:	Executive Director, Adrian Guillen		TIME COMPLETED:	05:15 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) Amy Rodgers, made an unannounced visit to conduct the required One-Year Inspection. LPA Rodgers was granted entry into the facility by Executive Director Adrian Guillen, after identifying herself and stating the purpose of the inspection. The facility serves 219 ambulatory elderly residents, age 60 and above, of which 33 may be non-ambulatory and 8 may be bedridden. There is an approved Hospice Waiver for 8 residents. This is a multi-unit complex including bungalow units as well as 2 buildings designated for a higher level of care. LPA was accompanied by Executive Director Guillen, during a tour of the facility, which was conducted inside and out and included a sample of resident units, the dining area, recreation rooms, and food storage areas. There is a fire signal system in place and the carbon monoxide detectors were operational. The last disaster drill was conducted on December 2023. Exterior and interior passageways were free from obstructions. According to executive Director Guillen, there are no weapons and/or ammunition stored on the premises. Pull cords were available in each resident units as well as personal pendants. LPA Rodgers observed functionality of signal system. Resident's room temperatures were within a comfortable range. Each resident had clean and sufficient bed linens, towels, and washcloths. All residents’ rooms were equipped with required furnishings. Lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Toilets and showers were equipped with grab bars, and non skid mats were present in some residents’ showers. Hot water temperature in residents’ bathrooms were compliant. [Continued on 809-C]

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: MONTE VISTA VILLAGE SENIOR LIVING	FACILITY NUMBER: 374604441
	VISIT DATE: 01/12/2024

NARRATIVE

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[Continued on 809]

Facility has a two-day supply of perishable and a seven-day supply of nonperishable food items. Food supply is replenished frequently by outside vendors. Food was observed to be properly stored and labeled. Food menus and activities schedule were posted. Chemicals and cleaning supplies were stored in a locked room. The medication room is located in the higher level of care buildings and in which the medication carts are located. Medications were labeled and kept in compliance with label instructions.

LPAs interviewed multiple staff and clients. LPA reviewed multiple staff and client records/files. The interviews did not raise any significant licensing concerns. The reviewed files contained all required documents. LPA Rodgers also conducted a review of In-service training procedures. Confidential records were stored in locked areas. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs.

No defiencies were issued at the time of th evisit, however there were advisory notes issued.

An exit interview was conducted and a copy of this report,Licensee/Appeal Rights - LIC 9058 (rev. 01/16), and the 9102TA, were provided to the Executive Director Guillen, whose signature on this form acknowledges receipt of these documents.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024

LIC809 (FAS) - (06/04)

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