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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191500496
Report Date: 12/06/2024
Date Signed: 12/06/2024 03:32:01 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 12/06/2024 03:32 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:MOUNT SAN ANTONIO GARDENSFACILITY NUMBER:
191500496
ADMINISTRATOR/
DIRECTOR:		JOYCE FREMPONGFACILITY TYPE:
741
ADDRESS:900 EAST HARRISON AVENUETELEPHONE:
(909) 624-5061
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY: 520CENSUS: 427DATE:
12/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Lindsay Mullen, Assitant DirectorTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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Licensing Program Analysts (LPAs) Mayra Cota, Elizabeth Irra and Luis De Leon conducted an annual inspection visit. LPAs met with Lindsay Mullen, Assistant Director and discussed the purpose of today’s visit. Joyce Frempong, Director of Assisted Living arrived thereafter.

This is a Continuing Care Retirement Community (CCRC) which consists of:
· Assisted Living (Oak Tree Lodge) - capacity of 70
· Memory Care (Taylor Villa) - capacity of 10
· Assisted Living (Harrison Villa) - capacity of 10
· Independent Living - currently housing 345

The Oak Tree Lodge has a capacity of 70 Residents (private rooms) and is currently housing 62 Residents. Taylor Villa has a capacity of (10) Residents (private rooms) and it currently houses (10) Residents. Harrison Villa has a capacity of (10) Residents (private rooms) and currently houses (10) Residents. Total census for this facility is 427.

LPAs utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:
Infection Control: Facility has an Infection Control Plan in place.
Operational Requirements: Facility is adhering to the operational requirements.
Staffing: Facility is adhering to staffing requirements.

Personnel Records-Training: Staff files are maintained at the facility. LPAs reviewed staff files for Facility Director (S-1) through Staff #10 (S1-S10). Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file. Staff are also trained on Abuse Reporting and Resident Rights. **Refer to LIC 809C for the continuation of this report***
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Mayra Cota
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2024
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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: MOUNT SAN ANTONIO GARDENS
FACILITY NUMBER: 191500496
VISIT DATE: 12/06/2024
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Resident Records-Incident Reports: LPA reviewed Resident files for Resident #1 (R-1) through Resident #10 (R-10). Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent For Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan, Resident Rights were observed.

Resident Rights-Information: Resident rights are posted and included in Resident files.
Planned Activities: Facility has an Activities Assistant Director. Activity schedules are posted.
Disaster Preparedness: The facility has a Disaster Preparedness plan in place.

Residents with Special Health Needs: There are residents utilizing oxygen equipment and “Oxygen is Use” signs are posted. There are residents under hospice care. Staff have training for Care of Persons with Dementia.

Physical Plant & Environment Safety LPAs 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 January 2024. Maintenance staff check fire extinguishers on a monthly basis (last checked 12/3/2024). Fire alarms were tested and operable in all toured buildings. Signal systems were tested and operable. Last fire drill was conducted on 11/26/2024. Resident's rooms 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.

NOTE: LPA was experiencing technical difficulties during this visit.

Exit interview conducted, appeal rights and a copy of this report was provided to Joyce Frempong.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Mayra Cota
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
LIC809 (FAS) - (06/04)
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