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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191500496
Report Date: 01/25/2024
Date Signed: 01/25/2024 01:15:27 PM

Document Has Been Signed on 01/25/2024 01:15 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: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: 380DATE:
01/25/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Lindsay MullenTIME COMPLETED:
01:30 PM
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Licensing Program Analysts (LPA) Elizabeth Irra conducted a subsequent annual inspection visit. LPA met with Lindsay Mullen and discussed the purpose of today’s visit. Joyce Frempong arrived at approximately 10:30 A.M..

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:
Physical Plant & Environment Safety: LPA toured facility grounds (Assisted Living Building, Harrison Villa and Taylor Villa). Carbon Monoxide detectors were observed in each building (tested and operable). Fire extinguishers are located throughout the buildings. Fire extinguishers were last serviced on 01/23/2023. Maintenance staff check fire extinguishers on a monthly basis (last checked 01/02/24). Per Ms. Mullen, the fire extinguishers are being serviced/checked today (while LPA in on premises). Signal system were tested and operable in the following rooms and were operational: Room L-4 (Assisted Living), Room L-30 (Assisted Living), Harrison Villa-Magnolia, Harrison Villa- Cypress, Taylor Villa-Cedar and Taylor Villa-Sequoia. Hot water temperature measured within regulations. The hot water supply measured at the following temperatures: Room L-4 (Assisted Living)/111.0*, Room L-30 (Assisted Living)/117.0*, Harrison Villa-Magnolia/109.0*, Harrison Villa- Cypress/115.0*, Taylor Villa-Cedar/112.0* and Taylor Villa-Sequoia/113.0*. Bathrooms had non-skid surfaces and grab bars. Rooms have all required furniture.

Food Service: There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. The food is properly stored in the refrigerator. Posted menu observed. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly. Dining areas have adequate seating.

Health Related Services/Incidental Medical Services: The medications are stored and locked. Medications are administered as prescribed. Medication Administration is documented in a Medication Administration Record (MAR) log.
**Exit interview conducted, copy of appeal rights and a copy of this report was provided to Joyce Frempong**
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/25/2024
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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