<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191500496
Report Date: 09/13/2021
Date Signed: 09/13/2021 02:35:21 PM

Document Has Been Signed on 09/13/2021 02:35 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:MOUNT SAN ANTONIO GARDENSFACILITY NUMBER:
191500496
ADMINISTRATOR:JOYCE FREMPONGFACILITY TYPE:
741
ADDRESS:900 EAST HARRISON AVENUETELEPHONE:
(909) 624-5061
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY: 520CENSUS: 0DATE:
09/13/2021
TYPE OF VISIT:Case Management - Licensee InitiatedANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Vice President Health Case Services, RCFE Administrator/Director Assisted Living and Memory Care CoordinatorTIME COMPLETED:
03:00 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) Elizabeth Irra conducted an announced visit to conduct a walk-through for the Taylor Villa (was previously Mount San Antonio Gardens Skill Nursing Facility). This location received a Fire Inspection clearance for the following: (10) non-ambulatory beds with delayed egress gates. LPA met with Vice President Health Case Services, RCFE Administrator/Director Assisted Living and Memory Care Coordinator and conducted a tour of this location.

This location will be utilized to provide care and supervision for (10) non-ambulatory Memory Care Residents ages 60 and above. Each Resident will have their private room (with private full bathroom). This facility also consists of a large dinning room, (2) common area bathrooms, den, nurses station, kitchen, laundry room, spa room (Beauty/Wash Room).

During this visit, LPA observed the following:
  • Smoke detectors operate properly.
  • Carbon monoxide detector was tested and operable. Located in the laundry room.
  • Fire extinguisher (3). All serviced on: 01/21/2021. (1) in the kitchen, (1) nurses station and (1) in the spa room.
  • Signal System tested and operable.
  • Cleaning solutions are locked inside a closet near the dinning area.
  • Sharps such as knives are locked inside the kitchen the kitchen cabinet.
  • Building and grounds are free from hazards.
  • Physical plant is in good repair.
  • Beds have the required linen/supplies.
  • Mattresses and bedsprings are in good repair.

Refer to LIC 809C for the continuation of this report
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2021
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: MOUNT SAN ANTONIO GARDENS
FACILITY NUMBER: 191500496
VISIT DATE: 09/13/2021
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
26
27
28
29
30
31
32
  • Bedrooms are large enough to allow for easy passage between and comfortable for usage of beds and other required items of furniture. Each Resident has their own private room.
  • Residents have the appropriate furniture.
  • There are enough bath towels, hand towels and wash cloths for all Residents.
  • There are sufficient amount of linens available to permit weekly changing to ensure use of clean linens at all times by Residents.
  • Pantry's cupboards, freezers, stoves, microwaves, refrigerator and counters are clean.
  • Two day supply of perishables available, seven day supply of non-perishable available.
  • The facility has large dinning room table with appropriate seating.
  • Resident files and staff files will be locked inside a cabinet in the nurses station.
  • Medication will be locked inside a cabinet in the nurses station.
  • First Aid Kit inspected.
  • Window screens are in good repair and windows shades are in good repair and operate properly.
  • Refrigerator, stove, telephone, sinks, tubs, toilets and showers operate properly.
  • Hot water temperature measured at 116*.
  • Personal rights, Emergency Disaster Plan, Complaint Procedures are posted.
  • COVID-19 signs are posted throughout the facility including the entry door.
  • PPE supplies were observed.


NOTE: Existing Residents from the Memory Care will be moving into this location (once licensed). LPA observed the following at the current (Memory Care) location: Resident Bedroom Furniture, Food Supply, PPE Supply, First Aid Kit and Manual and linens.

Exit interview conducted and a copy of this report was provided to Vice President Health Case Services
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2