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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191500496
Report Date: 02/03/2022
Date Signed: 02/04/2022 08:05:07 AM

Document Has Been Signed on 02/04/2022 08:05 AM - 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: 76DATE:
02/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:S-1/Assistant DirectorTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced Required-1 year visit focusing on COVID-19 Infection Control Practices. LPA met with S-1 and discussed the purpose of today's visit.

This is a Continuing Care Retirement Community (CCRC) which consists of Assisted Living (Oak Tree Lodge), Memory Care (Taylor Villa) and Independent Living. The Oak Tree Lodge has a capacity of 70 Residents (private rooms). There are 67 Resident currently residing at the Oak Tree Lodge. The Memory Care has a capacity of 10 Residents (private rooms) and it currently houses 9 Residents.

The following were observed/inspected: .
  • COVID-19 Infection Control Practices (including signs) were observed at the entrance of this facility and throughout the facility.
  • Signs are posted to promote hand washing, cough/sneeze etiquette, and physical distancing were observed.
  • PPE supplies observed.
  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed. The main campus kitchen was toured as the majority of food supply is stored there.
  • Medication reviewed for R-1 through R-6.
  • Per Assistant Director, all Residents (Assisted Living and Memory Care) are fully vaccinated. There are (2) Residents that are pending their booster.
  • Per Assistant Director, Staff are vaccinated. However, 31 of the staff have their booster pending. Only (1) staff has a religious exemption and is tested on a routine weekly basis.
  • Staff responsible for direct care and supervision will wear masks.
  • Residents were be socially distanced according to local public health guidelines.

Exit interview conducted, a copy of this report and Appeal Rights were provided to S-1/Assistant Director
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 02/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2022
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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