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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603383
Report Date: 09/05/2025
Date Signed: 09/05/2025 05:41:37 PM

Document Has Been Signed on 09/05/2025 05:41 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:TERRACES AT VIA VERDE-A MEMORY CARE COMMUNITY, THEFACILITY NUMBER:
198603383
ADMINISTRATOR/
DIRECTOR:		JAKINI, ROBERTFACILITY TYPE:
740
ADDRESS:1155 VIA VERDETELEPHONE:
(909) 293-6466
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY: 60CENSUS: 44DATE:
09/05/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:19 AM
MET WITH:Subishsani Kumar, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
05:45 PM
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Licensing Program Analysts (LPAs) Galarza and Gabriela Castro conducted an unannounced Required- 1 year visit. The purpose of the visit was explained to Executive Director Subishsani Kumar. The Residential Care For Elderly (RCFE) facility serves cognitively impaired residents ages 60 and over.

The following were observed/inspected:



Infection Control: The Infection Control Plan was reviewed. The facility has sufficient supply of Personal Protective Equipment (PPEs).

Operational Requirements: The facility has a hospice waiver for 20 residents. All bedrooms are approved for non-ambulatory residents. Facility does not handle resident monies. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is current with an expiration date of 2/1/2026. The facility entire facility serves residents with Dementia.

Physical Plant/Environment Safety: Facility is a 2-story building consisting of 43 resident rooms, 2 activity rooms, outdoor courtyard, 2 dining rooms, side patio in 1st floor, 2nd floor terrace patio, conference room, lobby room, kitchen, employee lounge, and office.The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. There is a water fountain located in the 1st floor. Cleaning supplies and toxic substances are inaccessible to residents. Most beds had required bedding, linens, and mattress pads with the exception of 10 beds. The signal system was tested and is operational. Water temperature readings did not measure within tthe required 105 - 120 degrees Fahrenheit. There are evacuation chairs on facility stairwells to be used during an emergency as a path of egress from the facility to safety. The facility is equipped with sprinklers, smoke detectors, carbon monoxide detectors, and has charged fire extinguishers. The last fire inspection was conducted on 3/13/25 by State of CA Fire Marshall. Rooms 110, 115, and 210 had oxygen tanks in the rooms but no signs of "No Smoking-Oxygen in Use".

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: TERRACES AT VIA VERDE-A MEMORY CARE COMMUNITY, THE
FACILITY NUMBER: 198603383
VISIT DATE: 09/05/2025
NARRATIVE
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Staffing: A total of 37 staff members provide care and supervision to the clients.

Personnel Records/Staff Training: Administrator certificate expires 12/27/2025.. Staff have criminal background clearance. 10 staff files were reviewed. They contained 1st Aid/CPR training, criminal background clearance, health/TB screenings, 1st Aid/CPR training, and training records. Administrator on record is not current. A citation was issued.

Resident Records/Incident Reports: 10 resident files were reviewed. They contained admission agreements, Service Plans, Physician's Reports, Appraisals, TB clearance, Physician's Orders, medical consent. Centrally stored medication records were reviewed. R6's medical assessment is dated 7/28/23; a citation was issued.

RCFE & Ombudsman complaint posters are posted near the main entrance. A technical advisory was issued pertaining to the size of the RCFE poster.

Planned Activities: Facility activity calendar was posted. Sufficient space to accommodate both indoor and outdoor activities was observed.

Food Service: Food supply was checked in the kitchen and pantry storage areas, consisting of 2-day perishables, 7-day non-perishables, and emergency food supplies. 18 residents have physician orders for modified diets. A diet list was observed in the kitchen. Sanitation practices and kitchen cleanliness was observed. Director of Culinary Services Food Handling Certificate is current.

Incident Medical and Dental: Centrally stored resident medications were reviewed; containing a 30-day supply of medications. Medical and dental transportation is provided by family or facility van. R1 & R2 were missing medications. A citation was issued.

Disaster Preparedness: Emergency and Disaster Plan LIC 610E was reviewed. Facility has a First Aid Kit and Manual. The last emergency disaster drill was conducted on 9/3/2025.

Residents with Special Health Needs: There are currently 16 residents receiving hospice services, 2 receive home health services, and no residents have prohibited health conditions. Individual Service Plans and Appraisals are on file. Postural support physician orders are on file.

Per California Code of Regulations, Title 22, deficiencies were cited.



Exit interview, copy of report/appeal rights was conducted with Executive Director Subishsani Kumar.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/05/2025 05:41 PM - It Cannot Be Edited


Created By: Noemi Galarza On 09/05/2025 at 04:30 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: TERRACES AT VIA VERDE-A MEMORY CARE COMMUNITY, THE
FACILITY NUMBER: 198603383

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87407(k)(1)
Personnel Administrator Recertification Requirements.
Whenever a certified administrator assumes or relinquishes responsibility for administering a residential care facility for the elderly, he or she shall provide written notice, within thirty (30) days, to: (1) The local licensing office .....
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that Executive Director Subishsani Kumar was hired on 4/15/25 and Licensee failed to report changes to CCL within 30 days. This poses a potential health and safety risk to persons in care.
POC Due Date: 09/19/2025
Plan of Correction
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Executive Director agreed to submit proof of correction, which includes all required forms to CCL by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Noemi Galarza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/05/2025 05:41 PM - It Cannot Be Edited


Created By: Noemi Galarza On 09/05/2025 at 04:40 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: TERRACES AT VIA VERDE-A MEMORY CARE COMMUNITY, THE
FACILITY NUMBER: 198603383

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)(3)(C)
Personal Accommodations and Services
(C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. The use of common wash cloths and towels shall be prohibited.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that rooms 101, 106, 107, 111, 114, 202, 210, 216, 217, 219 beds did not have mattress pads, which poses a potential health, safety or personal rights risk to persons in care
POC Due Date: 09/19/2025
Plan of Correction
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Executive Director agreed to submit proof that the resident beds in rooms 101, 106, 107, 111, 114, 202, 210, 216, 217, 219 have mattress pads.
Type B
Section Cited
CCR
87463(h)
Reappraisals
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that R6's last medical assessment is dated 7/28/2023, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/19/2025
Plan of Correction
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Executive Director agreed to submit a copy of R6's medical assessment.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Noemi Galarza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/05/2025 05:41 PM - It Cannot Be Edited


Created By: Noemi Galarza On 09/05/2025 at 04:40 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: TERRACES AT VIA VERDE-A MEMORY CARE COMMUNITY, THE
FACILITY NUMBER: 198603383

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87618(b)(3)(B)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that rooms 110, 115, and 210 had oxygen tanks in the rooms but no signs of "No Smoking-Oxygen in Use" signs were observed outside the resident room door or in appropriate areas, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/19/2025
Plan of Correction
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Administrator shall ensure that a No Smoking-Oxygen In Use sign is posted when oxygen tanks are in the facility.
Submit picture proof that the signs are posted.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Noemi Galarza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/05/2025 05:41 PM - It Cannot Be Edited


Created By: Noemi Galarza On 09/05/2025 at 05:00 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: TERRACES AT VIA VERDE-A MEMORY CARE COMMUNITY, THE
FACILITY NUMBER: 198603383

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465©(2)
Incidental Medical and Dental Care. If the resident's physician has stated in writing that the resident is unable to determine his/her own need ........ facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: Once ordered by the physician the medication is given according to the physician's directions.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that R1’s Levothyroxine Sodium 75 mcg has not been filled and was last administered on 8/25/25, as well as R2’s Hyoscyamine sulf 0.125mg PRN has not been filled, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/06/2025
Plan of Correction
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Executive Director agreed to submit proof by tomorrow that R1 and R2's medications were filled. In addition, all med-tech staff shall receive medication administration training and documentation procedure training. Submit proof of training by 9/10/25.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Noemi Galarza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2025


LIC809 (FAS) - (06/04)
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