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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191500496
Report Date: 11/10/2022
Date Signed: 11/10/2022 11:31:58 AM

Document Has Been Signed on 11/10/2022 11:31 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
GREATER LA AC/SC, 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: 7DATE:
11/10/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Lisa Atilano and Joyce FrempongTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted an announced visit to conduct a walk-through for the Harrison Villa. This building was licensed through Department of Public Services as a Skilled Nursing Facility (SNF). This location received a Fire Inspection clearance for the following: (10) non-ambulatory beds. LPA met with Lisa Atilano and Joyce Frempong and conducted a tour of this location.

This facility also consists of the following: a large dinning room, (2) common area bathrooms, den, nurses station, kitchen, laundry room, spa room (beauty salon). Each Resident has their private room (with private full bathroom- bathrooms have hand washing signs, hand sanitizer and paper towels).

During this visit, LPA observed the following:
  • Fire alarms tested and operate properly.
  • Fire extinguisher (3). All serviced on: 10/18/2022. Location: (1) nurses station, (1) kitchen and (1) near Elm room towards the exit. A floor plan is posted which reflects the location of all fire extinguishers.
  • Signal System tested and operable.
  • Carbon monoxide detector was tested and operable. It is located inside the laundry room. LPA recommendedanother to be placed near the kitchen.
  • Cleaning solutions are locked inside the housekeeping closet. Sharps such as knives are stored and locked.
  • Building and grounds are free from hazards.
  • 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 and have the appropriate furniture.
  • Linens available to permit weekly changing observed. There are enough bath towels, hand towels and wash cloths for all Residents.
Refer to LIC 809C for the continuation of this report
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/10/2022
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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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: MOUNT SAN ANTONIO GARDENS
FACILITY NUMBER: 191500496
VISIT DATE: 11/10/2022
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  • Pantry's cupboards, freezers, stoves, microwaves, refrigerator and counters are clean.
  • Two day supply of perishables available, seven day supply of non-perishable available. Emergency food supply observed inside the pantry room.
  • The facility has large dinning room table with appropriate seating.
  • Resident files and staff files are locked in the nursing station.
  • Medications are locked inside a wall cabinet in each residents room (nurse has the keys for all locks).
  • First Aid Kit inspected (thermometer, tweezers and scissors included). Kit located in the nurses station.
  • 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. All bathrooms have non-skid flooring and hand rails.
  • Hot water temperature was measured. Common area restrooms: 116.7*. Jacaranda room: 118.6*. Redwood room: 115.5*.
  • Personal Rights, Emergency Disaster Plan, Complaint/Grievance Procedures observed near the main entrance.
  • COVID-19 signs observed.
  • PPE supplies were observed.
  • Incontinence supplies were observed.
  • Hygiene supplies were observed.

Exit interview conducted and a copy of this report was provided to Lisa Atilano and Joyce Frempong
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022
LIC809 (FAS) - (06/04)
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