Monte Vista Grove Homes

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cynthia Chan conducted an unannounced annual inspection on 10/13/25 using the Compliance and Regulatory Enforcement (CARE) tools. LPA met with Staff, Nancy Mandic, who provided the tour of the facility. The assistant administrator, Meagan Swan, arrived later to assist with the rest of the inspection. The facility is licensed to serve 66 residents, of which (26) may be non-ambulatory and (40) bedridden. There is a hospice waiver approved for (15) residents. The licensed part of the campus consists of (3) cottages called The Hearth, Stewart Cottage, and The Ranch House (Memory Care unit). The Commons building consists of the dining area and kitchen. The liability insurance is maintained at a $1 million for each occurrence and $3 million in total general aggregate. LPA observed the following during the visit today: The Commons building is comprised of a library area, mail room, business offices, dining room, an outdoor dining area, and a commercial kitchen. The food preparation areas were clean. There was adequate supplies of both perishables and nonperishable items. The cleaning supplies are kept in away from the food area. The Hearth building is comprised of resident rooms, activity room, a laundry room, and the medication room. LPA selected (3) rooms (rooms #8, #13, and #15) to inspect. The bathrooms have skid mats, grab bars, and the water temperature was within the required range. Stewart Cottage is comprised of resident rooms, activity room, two family rooms, a shower room, medication room, and a few offices. LPA selected (3) rooms (rooms #4, #7, #12) to inspect. The bathrooms have skid mats and the water temperature was measured within range. The Ranch House (Memory Care unit) is comprised of resident bedrooms, a kitchenette, a library room, a living/dining room area, medication room, and an enclosed outdoor patio. This building has a delayed egress system. The rooms are clean and have sufficient lighting. The hot water was measured within the required range. Each building has a fire sprinkle system installed. Carbon monoxide detectors and fire extinguishers were also observed. The outdoor center area has a pond that is less than 2 ft in depth and is protected with wires. The swimming pool is surrounded by a 5ft fence. LPA selected (7) resident files for review. Each of the files has the admission agreement, consent forms, medical assessment with TB test results, resident's reappraisal plan, and the property valuable form. The medications for these residents were also reviewed and no discrepancies were found. LPA reviewed (5) staff files. Staff have the required documents such as the personnel record, health screening and TB results, first aid training and CPR certificates. Administrator's (Deborah Herbert) certificate expires on 5/2/27. Staff are receiving annual training on dementia care and medication. The Emergency Disaster Plan is reviewed annually and disaster drills are conducted at least monthly for all shifts. No deficiencies were issued today. Exit interview was conducted with Meagan Swan and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 13, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced case management visit regarding incident report submitted to the department on 2/27/24. LPA met with Meagan Swan and explained the reason for the visit. On 2/27/25 Facility staff submitted an incident report to the department to report that on 4/21/25 Staff #1 had inappropriate interactions with an independent living resident in the facility. Per incident report dated 2/27/25 Staff #1(S1) made comments and approach Resident #1(R1) inappropriately on 4/21/25 at R1's residence. S1 was given a termination letter on 2/25/25 due to a complaint towards the staff and violation of the facility's policy and expectations. During today's visit LPA interviewed R1, administrator, and 5 staff and obtained copies of application, termination letter of S1, emails, and incident report. Facility administrator will submit a suspect of dependent adult/elderly abuse (SOC 341) to the proper agencies and department by end of day today. Exit interview was conducted with Meagan Swan and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 27, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Meagan Swan 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), a kitchen and dining area in the Commons building. LPA Flores conducted a tour with Meagan Swan and observed the following: The Commons - is composed of a library area, mail room, offices, dining room, an outdoor dining area and commercial kitchen. The building is in good repair and each area is properly furnished. The kitchen was observed clean with refrigerators, freezers, and walking pantry which store at least 2 days of perishables and 7 days of non-perishables. The Hearth - is composed of different studio resident rooms with private bathrooms, an activity room, and a medication room. Activity room was observed furnished and fireplace was covered. Three rooms were observed with sufficient lighting, furniture, and bedding supplies. Bathrooms were observed in good repair, each with skid mats, and grab bars, and water temperature was tested between 109.2 - 114.5 degrees F. Stewart - is composed of resident rooms some with half bathrooms and some with full bathrooms. A dining/activity room, two family rooms, a shower room, a medication room, and a few offices. Three rooms were observed with sufficient lighting, the required furniture and bedding supplies. Bathrooms in each room were observed in working condition with grab bars. Rooms #12 and #18 did not have skid mats/strips. Water temperature was tested between 80.9 - 105.8 degrees F. The Ranch (dementia unit) - is composed of resident bedrooms with private bathrooms, a kitchenette, a living/dining room area, a medication room, and a fenced outdoor patio. (CONTINUED ON LIC 809C) Each exit has a delay egress system. Kitchenette was observed clean, under sink cabinet was observed to store chemicals and was unlocked at the time of the visit. Two rooms were observed with sufficient lighting, furniture, and bedding supplies. Water temperature was tested between 103.0 - 107.6 degrees F. Water temperature in room #12 in Stewart cottage was tested at 80.9 degrees F., which is not within the required 105-120 degrees F. Fire sprinkle system is installed in each building and are in working condition. Fire extinguishers were observed. Residents' beds that were observed with bed rails have a bed rail request on file. Garden walk area outside the Commons has two fish/turtle ponds that are wired across and less than 2 ft in depth. Community's pool has a 5ft fence. At around 1:15pm LPA observed Resident #6(R6) using a merry walker at the facility and no postural support physician's request was noted by a physician. Files and medication was checked for 5 residents. Hospice file was observed for one resident. Five (5) staff files were reviewed. Staff #3(S3) does not have 20 hours of training within the last 12 months. Administrator certificate was observed for Deborah Herbert #6003728740 exp. date: 5/2/25. At least one staff during each shift has a current First Aid/CPR training certificate. Infection Control and Emergency disaster plans were reviewed and have been reviewed/updated within the last 12 months. Exit interview was conducted with Meagan Swan and a copy of this report, LIC 809D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Nov 7, 2024

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 (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.