Monte Vista Grove Homes

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Mary Flores and Office Technician (OT) Jade Xu conducted an unannounced annual investigation visit using the CARE inspection tool. LPA met with Nancy Mandic and explained the reason for the visit. Facility is licensed to serve 66 residents over 59 years old of which 26 may be non-ambulatory and 40 may be bedridden. Facility is approved to retain/accept fifteen (15) hospice residents. Facility is a campus area with separate cottage buildings which are identify as the Ranch House (Dementia unit), the Hearth and Stewart Cottage (Assisted Living). LPA, OT, and Nancy Mandic toured the facility and observed the following: The Commons which consist of facility's kitchen, library, and dining area: The kitchen is currently under construction due to plumbing issues which started on September 2023. A temporary trailer kitchen is set up outside the dining area for meal preparation. The trailer has a walking refrigerator and a small freezer which stores food for the 2 days worth of perishables, and the pantry is currently in the administration building which stores 7 days of non-perishables. The dining room and library are clean with sufficient seating area. Upon exiting the building towards the independent living there are two ponds protected by wire over them and a 5ft fenced on the bridge. A fence pool is in the back. The Hearth: Has it's own smaller dining room with a glass screen - fireplace, activities supplies are stored and accessible to resident. Three (3) private bedrooms were observed each have sufficient lighting, furniture, and bedding supplies. Bedroom #3 does not have a bed per residents choice. Bathrooms were observed in working condition, with skid mats/grab bars, and water temperature was tested between 102.7 - 108.6 degrees F., which is not within the required 105-120 degrees F. The Ranch House (Dementia Unit): Has a kitchenette with a small refrigerator for snacks. Drawer was observed with a lock unlock during the visit with a pair of large scissors, and cleaning solution bottle was accessible to the residents next to the microwave. Medication room was locked.(CONTINUED ON LIC 809C) Egress system is in working condition, the building has a fenced patio for outdoor activities with shaded seating area. Dining room is clean and in good repair. Three (3) bedrooms were observed; each room has sufficient furniture, bedding supplies, and lighting. Beds in rooms #3, and #6A were observed to have half bed rails, and bed in room #7B was observed to have a half and a attached rail which make a full bed rail. No physician's request on file for bed rails. Bathroom were observed clean and in working condition, water temperature was tested between 106.1 - 112.1 degrees F. which is within the required 105-120 degrees F. The Steward: It's currently under remodeling which was notified to the department in 2022. It has a clinical room, 3 offices, a medication room, the nurse station has been remove and it will be turn into a seating area. Dining area and kitchenette to prepare snacks. Two (2) bedrooms were observed, both with sufficient lighting, furniture, and bedding supplies. Beds in both rooms have half bed rails. No physician's request on file for bed rails. Room #6 has a half bathroom and room #14 has a full bathroom, both are in working condition, with grab bars, skid was not observed, and water temperature was tested between 109.5 - 109.9 degrees F. A common shower was observed with grab bars, no skid mat was observed. LPA observed construction on the parking lot in front of the The Commons, the Hearth, and the Ranch. Caution tape is placed. Permits were reviewed. This was not notify to the department as of 11/2/23. Fire sprinkle system was observed throughout the buildings. Fire extinguishers were observed throughout and last checked on 12/25/22. Last emergency drill was conducted on 10/18/23. Medication was reviewed for 6 residents. Files were reviewed for 5 residents and 5 staff. Administrator certificate was observed for Deborah Herbert #6003728740 exp. date: 5/2/25. Interviews were conducted with 3 staff and 3 residents. Exit interview was conducted with Deborah Herbert and a copy of this report, LIC 809D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Nov 2, 2023

The state marks this report as 7 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced annual visit at the facility with focus on infection control domain, food and medication review. LPA Flores met with Meagan Swan and Nancy Mandic Assistant Administrators and explained the reason for the visit. Facility is licensed to serve 66 residents over 59 years old of which 26 may be non-ambulatory and 40 may be bedridden. Facility is approved to retain/accept fifteen (15) hospice residents. Facility is a campus area with separate cottage buildings which are identify as the Ranch House (Dementia unit), the Hearth and Stewart Cottage (Assisted Living). LPA conducted a tour of the campus with Meagan Swan and Nancy Mandic Assistant Administrators and observed the following: The Commons/dining area was observed with sufficient sitting area, and social distancing was practice during the visit. A library area with sitting area. Commercial kitchen was observed clean and in good repair. Sufficient food was observed for at least 2 days of perishables and 7 days of non-perishables. A tour of the Hearth was conducted and observed resident(s) room #15 and #2, each room with sufficient lighting, required furniture, and bedding supplies. Bathrooms were observed in each room in working condition, with the required grab bars, and skid strips, water temperature was tested as follow; room #15 tested at 71.0 degrees F. and in #2 tested at 63.1 degrees F. which is not within the required 105-120 degrees F. Facility noticed the issue the night before the visit and has a work order in place. The building has a courtyard with shaded sitting area and a family room with proper signage regarding infection control practices. A tour of the Stewart Cottage was conducted and observed resident(s) rooms #5,11,14,19 with sufficient lighting, bedding supplies, and furniture. Shared shower was observed with grab bars, bathrooms in room #11,14, and 19 were observed with grab bars and in working condition, no skid mats/strips were observed in the bathrooms for room #11, 14, 19 or the shared shower. Proper infection control signage was observed throughout the building. (CONTINUED LIC 809C) LPA did not tour the Ranch/dementia unit as they are currently in isolation due to COVID 19. The private patio for the Ranch was observed to provide shaded sitting area has a fence water fountain. The outdoor campus has a fence - lock pool, and two fish ponds that are located in the independent living area. Each building has a fire sprinkle system and smoke/carbon monoxide detectors which are hard wired and interconnected. There are alarms on all exterior doors, and they were tested and operational at the time of visit. The fire extinguishes observed and last maintained on 12/28/22. Administrator certificate was observed for Nancy Mandic #6019341740 exp: 9/8/24. LPA reviewed medication for 5 residents and did not have a 30 day supply for one or more medications per resident. No deficiencies were cited today.Technical violations and advisories were noted during this visit. Exit interview was conducted with Meagan Swan Assistant Administrator and a copy of this report and advisories were provided.the state’s words, verbatim · CDSS document, Feb 7, 2023

The state marks this report as 5 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced Required One (1) year - Inspection to this facility. Upon arrival, LPA met with Administrator Nancy Mandic and Licensee Deborah Herbert. The purpose of the visit was explained. Facility is licensed to serve 66 residents over 59 years old of which 26 may be non-ambulatory and 40 may be bedridden. Facility is approved to retain/accept fifteen (15) hospice residents. LPA used the infection control tool to evaluate the facility. LPA inspected the physical plant, COVID-19 procedures, reviewed residents' medications, observed food supply, and reviewed residents and staff files. Facility has submitted a mitigation plan and the plan has been approved. Facility is a campus area with different cottage buildings which are identify as the Ranch House, The Hearth and The Stewart Cottage. Each building has a fire sprinkle system and smoke detectors which are hard wired and interconnected (w/back-up battery) and were observed in the hallways and bedrooms. There are alarms on all exterior doors, and they were tested and operational at the time of visit. The fire extinguishes observed to be fully charged and meets regulations. A large body of water / pool area was observed at the facility which was gated and locked. All indoor and outdoor passageways are free of obstruction. Facility has several visiting areas indoor and outdoor. Outdoor areas are covered and have tables and chairs to accommodate the residents during visitations and outdoor activities. One entrance being utilized for each building at the facility, all required posters were posted at the entrance. Screening area is located in the entrance. Sign in sheet, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing mask during this visit. Continue 809C The resident’s bedrooms were inspected. All bedrooms were furnished with required furniture. Residents and common bathrooms are clean and operational w/grab bars and non-skid surface/mats in place. The hot water temperature was tested throughout the facility and measured within Title 22 Regulation guidelines. Common areas such as the living rooms, dining rooms, hallways, activity rooms, were inspected. All areas were clean and had the required furniture. Facility has one industrial kitchen and 2 serving kitchens. The industrial kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of 2 days of perishables 7 days of non-perishables. All chemicals and cleaning supplies locked in the storage areas. LPA observed the centrally stored medication areas to be locked and inaccessible to residents. The first aid kit was observed and found to be in compliance with the Title 22 Regulations. LPA reviewed 4 residents and 4 staff records. Residents' records were found to be complete and current. Staff files were reviewed, and documentation noted that facility staff maintain a criminal record clearance and associated to the facility. LPA randomly chose some residents' medications to review. Medications are documented properly and stored appropriately. Based on California Code of Regulations, Title 22, there were no deficiencies observed during the visit. A copy of the report was provided to the Administrator.the state’s words, verbatim · CDSS document, Mar 11, 2022

Type of visit: Case Management - Other

Licensing Program Analyst(s) (LPA) Mary Flores and Jewel Baptiste conducted a case management visit to follow up on capacity increase in which the current Skill Nursing Facility (SNF) building is turning into a residential care for the elderly (RCFE). Licensee submitted LIC 200 for an increase in capacity on 10/7/21. Facility has been approved by the Fire Department to serve a total of 66 residents over 59 years old of which 26 may be non-ambulatory and 40 may be bedridden on 10/25/21. Facility is a campus area with different cottage buildings which are identify as the ranch - dementia unit, the heart - RCFE, and the Stewart - SNF. Facility has a fire sprinkle system in each building. A large body of water was observed in the independent living area and it is not part of the 3 cottages. The Steward Cottage consist of 3 common rooms, and 21 rooms. LPAs observed the following: Activity/dining area, visitors room - room#2 and visitors lounge, and bedrooms #1,2,3,4,5,6,7,8,9,10,12,15, 16,17,18, 19,20,21, all in good condition. Residents rooms have a hospital bed with bed rails, all the required furniture, lighting, and bedding. Each bedroom has a full bathroom except for rooms #1,3,4,5,6, and 7, which do not have a shower. The facility has a common shower across room #4. All bathrooms have the required grab bars and skid strips. Water temperature was tested in rooms #4,10, and 18 and visitors room (#2)and tested between 111.2 and 114.8 degrees F, which is within the required temperature of 105 to 120 degrees F. Fire extinguishers were located in each hall, medication carts were observed in the hallways and were maintained locked, chemicals and cleaning supplies locked in the storage areas. Facility has an industrial kitchen located in the Commons. LPAs observed at least 7 days of non-perishable and at least 2 days of perishable food supplies which include a variety; vegetables, fruits, and pastas .Refrigerator's temperature was observed at 40 degrees and freezer at 9 degrees per staff freezer has a defrosting cycle and temperature log showed temperature was at 0 degrees at 5:30am. (CONTINUED LIC 809C) Facility is following COVID 19 recommendations; such as local central entry and screening upon arrival for visitors, staff, and residents; screening logs were observed. Infection control signs were observed through out the facility. Hand washing signs were added to the common bathrooms and hand washing sinks. Trash cans are covered to allow proper disposal of waste. LPAs observed PPEs supplies sufficient for 30 days. Medication was reviewed for resident #1, and #2 and a resident file mock was reviewed. LPAs reviewed physician's request for all current SNF residents to transition into RCFE, and physician's order for bed rails. No deficiencies were observed during this visit. Facility's physical plant follows Title 22 Regulations. Exit interview was conducted with Deborah Herbert and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 15, 2021

Type of visit: Office

An informal office meeting was conducted via Microsoft Teams with Regional Manager(RM) Araceli Ramirez , Licensing Program Manager(LPM) Fernando Fierros , Licensing Program Analyst(LPA) Mary Flores , Staff Service Manager I Allison Nakatomi CDSS, Staff Service Manager II Hao Nguyen , Geraldine Regional Manager Department of Public Health Yamakawa Geraldine, Deborah Herbert Licensee/Administrator and Megan Swan Assistant Administrator regarding facilities change of Skill Nursing Facility(SNIF) into a Residential Care for the Elderly (RCFE). The following items were discussed during our meeting: Facility is seeking to convert SNIF into a RCFE and will continue to operate as a Continuing Care Retirement Center(CCRC). A change in capacity application was received on 10/5/21 and will be process in our regional office (RO). SNIF's current census is 19 residents per administrator. Administrator stated current SNIF residents will transition into RCFE, Facility will not provide care for residents with Prohibited Health Conditions. Facility will ensure appropriate placement will be seek for residents with prohibited health conditions. Facility will provide a packet with all current SNIF residents needs to LPA Flores. Administrator stated a Fire Clearance has been requested by the department and a walk through was conducted on 10/20/21. Department is waiting for granted approval form and will coordinate a visit with Allison Nakatomi for a facility visit. Facility will submitted a hospice waiver request for a maximum of 15 ill resident .Facility currently has a waiver request approval for 1 ill resident. Facility submitted a hospice waiver request on 10/26/21 for a maximum of 6 ill residents, however after clarifying application, facility will resubmit hospice waiver request for a maximum of 15 ill residents and wait for department's approval. A clarification on Care Partners role was provided to the department. Care partners will provide care as caregivers. Facility will submit a job description for Head Nurse to LPA Flores. Exit interview was conducted with Deborah Herbert, Licensee and a copy of this report was email for signature.the state’s words, verbatim · CDSS document, Oct 29, 2021