Mount San Antonio Gardens

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Allegation investigated: Facility is in financial distress. Licensee misrepresented their financial obligations under law. Facility did not raise rates in accordance with the applicable statutes.

Licensing Program Analysts (LPA) Nune Margaryan conducted an unannounced subsequent complaint visit to deliver complaint findings regarding the allegations listed above. LPA Margaryan met with Assistant Director Lindsay Mullen and Chief Operating Officer Lisa Atilano and explained the purpose of visit. This complaint is assigned, investigated, and completed by the Continuing Care Contracts Bureau. The initial visit was conducted by LPA Elizabeth Irra on 04/03/25. During the initial visit, LPA Irra obtained a copy of the resident and staff rosters and documents related to this complaint. Continue 9099C Unfounded On 03/25/2025, the Department received a complaint alleging that, “facility is in financial distress,” “licensee misrepresented their financial obligations under law,” and “facility did not raise rates in accordance with the applicable statutes.” Throughout the course of the investigation the Department conducted interviews and reviewed documentation relevant to the allegations. During the investigation, the Department reviewed the provider’s audited financial statements for Fiscal Years (FY) 2022 through 2025 regarding the allegation that the facility is in financial distress. The audited financial statements reviewed found that the provider is not in financial distress. Although the provider reported an operating loss of approximately $3.4 million, the loss included a non-cash depreciation expense of approximately $5.8 million. Additional revenues generated through investments and interest income offset the operating loss and resulted in a positive overall bottom line. From a cash flow perspective, the FY2025 Statement of Cash Flows reflected net cash from operating activities of approximately $10.4 million. The investigation found that this operating cash flow allowed the provider to fund investing activities, including equipment purchases and investments in financial securities, as well as financing activities such as long-term debt payments. With respect to liquidity, the documentation showed that the provider consistently maintained more than 400 Days Cash on Hand, representing approximately $48 million in cash and cash equivalents, as well as a current ratio exceeding 1:1. The Department also confirmed that the provider met the Continuing Care Contract Bureau reserve requirements for both operating reserves and debt service reserves. As of Fiscal Year End 2025, the required operating reserve of approximately $6.3 million was exceeded by approximately $33.5 million, and the required debt service reserve of approximately $3.25 million was exceeded by approximately $4.93 million. The Department also reviewed concerns related to the provider’s Homeship Fund (Fund), which may be available to residents who become unable to pay monthly care and service fees or other charges. Department staff confirmed that the Fund is maintained as a restricted asset on the Statement of Financial Position and that participation in the program is subject to specific qualifications and alternative payment arrangements agreed upon by the resident and the provider. Continue 9099C Analysis of the Fund reflected an overall decrease in value from approximately $1.8 million at Fiscal Year End 2020 to approximately $1.0 million at Fiscal Year End 2025, representing a decline of approximately 45%, with the most significant decrease occurring during Fiscal Year 2022. However, it was discovered that the provider’s Board of Directors has access to approximately $29.6 million in other limited-use funds that could potentially be utilized for this purpose. Additionally, the Fund continues to receive support through donations, bequests, and charitable gift annuities. During the investigation, the Department investigated the allegation licensee misrepresented their financial obligations under law, specifically if the provider misrepresented to their residents that they were subject to the requirements of Senate Bill (SB) 525. SB 525 applies to: “Residential Care Facilities for the Elderly that are affiliated with an acute care provider or owned, operated, or controlled by a general acute care hospital.” Based on the information reviewed, Department staff determined that the facility is not owned, operated, or controlled by a general acute care hospital and therefore is not directly subject to the requirements of SB 525. The Department further reviewed information related to the provider’s June 2024 employee wage increases. Documentation and statements provided during the investigation reflected that the provider implemented compensation adjustments in response to labor market pressures and broader wage increases occurring throughout the healthcare and senior living sectors and that the organization believed adjustments were necessary in order to remain competitive and maintain the quality of care and services provided to residents. While investigating the allegation, facility did not raise rates in accordance with the applicable statutes, the Department reviewed the Attachment to Form 7-1 included within the providers 2025 Annual Report for information related to the monthly care fee increase (MCFI) that became effective on October 1, 2024. Pursuant to Health and Safety Code section 1788(a)(22), monthly care fees are to be based upon projected costs, prior year per capita costs, and economic indicators. The documentation confirmed that the provider’s methodology for calculating the MCFI incorporated projected costs and consideration of economic indicators, as required by statute. Continue 9099C Documentation review further reflected that the provider’s projected Fiscal Year 2025 operating costs to exceed projected revenues, resulting in a budgeted operating deficit, as detailed within Form 7-1. Based on interviews, documents reviewed, and the financial analysis conducted, the Department has determined that the allegations of: facility is in financial distress, licensee misrepresented their financial obligations under law, and facility did not raise rates in accordance with the applicable statutes, are unfounded. A finding that the complaint is unfounded means that the allegations were false, could not have happened and/or is without a reasonable basis. Exit interview is conducted with Chief Operating Officer Lisa Atilano and the copy of this report is provided.the state’s words, verbatim · CDSS document, May 14, 2026 · control 28-AS-20250325170056

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced Annual Continuation Visit. LPA met with Joyce Frempong, Director of the facility, and the reason for the visit was explained. Lindsay Mullen, Assisted Director, facilitated today's visit This is a Continuing Care Retirement Community (CCRC) which consists of: · Assisted Living (Oak Tree Lodge) - capacity of 70; housing 68 · Memory Care (Taylor Villa) - capacity of 10; housing 10 · Assisted Living (Harrison Villa) - capacity of 10; housing 10 · Independent Living - currently housing 257 During today’s visit, LPA toured the facility grounds (Assisted Living Building, Harrison Villa and Taylor Villa). The physical plant was observed clean inside and out. Passageways, walking paths, ramps, and exits are free of debris and obstructions. LPA inspected (17) resident rooms. Rooms have the required furnishing and bedding. Rooms with oxygen tanks have the required postings. Oxygen tanks were observed to be stored properly. Residents’ bathrooms are kept clean and sanitary. Toilets and showers have safety grab bars and anti-skid mats. Call buttons in residents’ rooms in the Memory Care Unit were tested and found to be working properly. Water temperature in the bathrooms was tested and measured between 105-120 degrees F, which is within compliance range. ****Continues on LIC 809-C**** . The (3) facility kitchens were inspected. Refrigerators, freezers and other kitchen appliances were observed clean and working properly. The facility has sufficient food supplies of 2-day perishable and (1) week of non-perishable items. Food storage rooms are stocked, and dry goods are kept in food-grade storage bins with tightly fitting lids. Cleaning supplies and other toxins are stored away from food and kept locked. Facility keeps extra food on hand for disasters or other emergencies. The dining areas have adequate seating and are kept clean. Tables and chairs are wiped down after each meal service. Laundry rooms throughout the facility are kept clean and appliances are operational and in good repair. Several shaded areas in the outdoor environment were observed. Patio furniture in the shaded areas is in good repair and there is sufficient seating for residents. Carbon Monoxide detectors were observed in each building and were tested and working properly. Fire extinguishers are located throughout the buildings. Fire extinguishers were last serviced in February 2025. Fire alarms were tested and operable in all toured buildings. The facility is inspected by the local Fire Department yearly and their last inspection was conducted on 11/6/2025. During today’s visit, maintenance staff also tested the fire doors in the Harrison and Taylor Villas and were working properly. Lighting in the hallways is appropriate, and carpet and flooring was observed clean and safe. During today's visit, LPA conducted interviews with Staff 7- Staff 10 and Resident 1 - Resident 10. Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies are cited today. Exit interview conducted with Joyce Frempong, Director, and Lindsay Mullen, Assistant Director, and a copy of the report was providedthe state’s words, verbatim · CDSS document, Feb 12, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced required annual visit today. LPA met with Joyce Frempong, Director of the facility, and the reason for the visit was explained. Lindsay Mullen, Assisted Director, facilitated today's visit This is a Continuing Care Retirement Community (CCRC) which consists of: · Assisted Living (Oak Tree Lodge) - capacity of 70; housing 68 · Memory Care (Taylor Villa) - capacity of 10; housing 10 · Assisted Living (Harrison Villa) - capacity of 10; housing 10 · Independent Living - currently housing 257 During today’s visit, LPA conducted the following: LPA reviewed (15) resident and (12) staff files. · 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. · Staff files are maintained at the facility. Staff have Criminal Background Clearances, current First Aid/CPR certification, Health Screening and Tuberculosis Screening on file. Staff are also trained in Abuse Reporting and Resident Rights. ***Refer to LIC 809-C for the continuation of this report.*** LPA reviewed Emergency Preparedness Plan and Safety Drill Logs. · Emergency Preparedness Plan has all the appropriate elements and is up to date. · Facility conducts Disaster/Fire drills quarterly with AM, PM and NOC shift participating during each simulation. Last drill was conducted on 11/28/2025. LPA reviewed medication for (10) residents. · Medication is centrally stored in the Medicine Office. · Facility uses an electronic Medication Administration Record (MAR) to document medication distribution to residents. · Medication was observed to be dispensed following physician orders and documented accordingly. LPA conducted interviews with (5) staff. · Two (2) administrative and (3) LVN/Med-Tech staff were interviewed. Due to time constraints, continuation of this annual visit will be conducted during a subsequent visit. Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies are cited today. Exit interview conducted with Joyce Frempong, Director, and Lindsay Mullen, Assistant Director, and a copy of the report was providedthe state’s words, verbatim · CDSS document, Feb 10, 2026

Type of visit: Collateral

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced collateral visit at the facility to conduct interviews regarding a recent incident at a different licensed facility. LPA met with Joyce Frempong and explained the reason for the visit. The purpose of this visit was to conduct interviews with 6 residents regarding the incident that occurred at the residents' previous facility. Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 4, 2025

Type of visit: Required - 1 Year

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*** 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.the state’s words, verbatim · CDSS document, Dec 6, 2024

Allegation investigated: Staff did not ensure to provide a safe environment in the dining room

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation. LPA met with Joyce Frempong and explained the reason for the visit. The investigation consisted of the following: LPA requested a copy of staff and resident roster. LPA interviewed 8 residents and 6 staff and conducted a tour of the dining room. The investigation revealed the following: Regarding allegation: Staff did not ensure to provide a safe environment in the dining room. It is alleged residents had hot coffee spill on them due to coffee cup lids not fitting properly. During tour of the dining room, LPA observed a coffee station, which provides disposable cups and lids next to their self-serve coffee machine. Staff place a lid over a coffee cup which closed and fit properly. Interviews conducted revealed 8 out of 8 residents stated they feel safe at the facility, facility provides a safe environment throughout, and in the dining room. (CONTINUED ON LIC 9099C) Unsubstantiated Per residents they have not have any issues with the coffee cups or lids and have not observed any resident spill coffee or hot beverages on themselves due to the coffee lids not fitting on the coffee cups. Interviews with staff revealed 6 out of 6 staff have not observed any residents spill coffee on themselves, residents have not notified staff regarding spilling coffee or hot beverages on themselves. Per administrator, there haven’t been any incidents in which residents have spills coffee or a hot beverage on themselves that may have been reported or needed first aid/medical care. Executive chef, who oversees ordering kitchen supplies, explained that recently the distributor changed their coffee cups in their delivery order, once staff became aware of lids not fitting cups properly, new lids were order. The change of cups and lids has been done in the last 7 days and there are no current issues. Per staff the new lids were order within 24 hours from the moment they became aware of the issue. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Joyce Frempong and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 11, 2024 · control 28-AS-20240603153809

Type of visit: Case Management - Annual Continuation

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**the state’s words, verbatim · CDSS document, Jan 25, 2024

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Elizabeth Irra conducted a subsequent annual inspection visit. LPA met with Joyce Frempong and discussed the purpose of today’s visit. This is a Continuing Care Retirement Community (CCRC) which consists of Assisted Living (Oak Tree Lodge), Memory Care (Taylor Villa), Assisted Living (Harrison Villa) and Independent Living (currently housing 306). The Oak Tree Lodge has a capacity of 70 Residents (private rooms) and is currently housing 55 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 (9) Residents. Total census for this facility is 380. LPA 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. LPA reviewed staff files for Facility Administrator/S-1 through Staff #6 (S-6). 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. Resident Records-Incident Reports: LPA reviewed Resident files for Resident #1 (R-1) through Resident #6 (R-6). 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 Director. Per Administrator, activity schedules are posted. Disaster Preparedness: The facility has a Disaster Preparedness plan in place. Residents with Special Health Needs: Per Administrator, there are no residents with postural supports and no residents with prohibited health conditions. Per Administrator, there are residents utilizing oxygen equipment and there are residents under hospice care. Staff have training for Care of Persons with Dementia. The following domains remain pending: · Physical Plant & Environment Safety · Food Service · Health Related Services/Incidental Medical Services Exit interview conducted, copy of appeal rights and a copy of this report was provided to Joyce Frempong.the state’s words, verbatim · CDSS document, Jan 23, 2024

Type of visit: Case Management - Licensee Initiated

Licensing Program Analyst (LPA) Elizabeth Irra conducted an announced visit to inspect the newly developed building located within this campus. The current census for Assisted Living is 76 and the census for independent living is 326 for a total of 402. LPA met with Patricia Williams (CEO), Will Levitt (VP of Facilities), Jason Gonzalez (Plant and Engineering Manager), Ariana Villapudua (Director of Admissions), Joyce Frempong (Director of Residential Health Services/RFCE Administrator), Tom Billings (KAR Construction), Larry Sisneros (AIA Architect) and Eric Entrekin (Project Superintendent). LPA toured the building and inspected the following: This building consists of (3) floors with a total of (53) independent living units. The Fire Department provided clearance for this building (known as Cedars Building/independent living) on 12/07/2023. Rooms inspected: 112 (Atlantica), 116 (Cypress), 202 (Cypress), 205(Juniper), 307(Deodar) and 312 (Atlantica). All units consist of (1) or (2) bedrooms and/or (1) (1 and 1/2) or (2) bathrooms, living room, laundry room, kitchen, closet, storage space and balcony/patio. All units include all electric appliances (stove, microwave, refrigerator, washer, dryer). All units have their own thermostat to regulate their own room temperature. All full-sized bathrooms have grab bars inside the showers. All main bedrooms have a signal system for "daily check-ins" or assistance which is connected to the main campus server. Fire extinguishers were observed in the hallways and were last serviced on 11/20/2023. No deficiencies noted. Exit interview conducted and a copy of this report was provided to Joyce Frempong.the state’s words, verbatim · CDSS document, Dec 21, 2023

Allegation investigated: Facility is retaining a resident with a higher level of care needs. Staff are not ensuring that resident is eating properly.

Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced initial complaint investigation visit for the allegations above. LPA met with Administrator Joyce Frempong and the purpose of the visit was discussed. On todays visit, LPA Villalobos toured the physical plant, interviewed staff #1-#6 (S1-S6) and residents #1-#10 (R1-R10). LPA reviewed and collected documents from R1's file, the food menu, and the staff and resident roster. The investigation revealed the following: In regards to the allegation "Facility is retaining a resident with a higher level of care needs." it was alleged that R1 is not having their needs met by the facility as their clothes are not fitting and staff are not caring for R1.... Continued on LIC 9099-C Unsubstantiated (6) of (6) Staff interviewed denied the allegation. (10) of (10) Residents interviewed could not corroborate the allegation. Interviews do not show that R1 required a higher level of care not being provided by the assisted living portion of the facility. As a continuing care retirement community, there is a skilled nursing portion for residents to move into when needed. According to interviews and file review, it has not been determined that R1 is in need of moving to that portion at the moment. R2 is the power of attorney of health care decisions for R1 and also stated that R1 is not in need of being moved to the skilled nursing portion. R2 is also R1's spouse and shares the same room. Interviews with R1 and R2 did not show that the staff are not meeting R1's needs or that clothes are not fitting. Based on interviews, files reviewed, and observations, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. In regards to the allegation "Staff are not ensuring that resident is eating properly" it was alleged that R1 is not eating properly in the facility. (6) of (6) Staff interviews denied the allegation. (10) of (10) Residents interviewed could not corroborate the allegation. Interviews show that R1 is provided breakfast, lunch and dinner daily to their room. Interviews with staff also show that R1 is provided additional calorie dense drinks between meals. Interviews did show that R1 will at times not want to eat and will need reminders and encouragement. File review does show that the staff are to encourage R1 to eat their meals, are to cut up food for R1, and to provide between meal nourishment. Interviews with R2 stated that the facility staff are doing those things for R1. Staff interviews also stated that those things are being done for R1. LPA observed R1 receive in between meal nourishment as well as lunch during the time of this visit. Based on interviews, files reviewed, and observations, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 20, 2023 · control 28-AS-20231116170559