Westminster Gardens

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced Required- 1 year visit. LPA met with Eusebio 'Sev' Tienda, Director of Wellness and LPA explained the purpose of the visit. The facility is licensed to serve (200) non-ambulatory residents age 60 and above. Hospice waiver approved for six (6) residents and Memory Care approved for twelve (12) residents. Facility is approved to lock both exterior doors on the perimeter gates in the Memory Care unit (Hacienda Bldg.). Facility is a Continuing Care Retirement Community (CCRC) which includes separate buildings throughout the premises. The Assisted Living residents are located in the Memorial Lodge (ML) and Shu Lodge (SL). Memory Care Unit, which is located in the Hacienda Building, is approved for 12 residents. Currently, there are 30 residents in the Assisted Living, 10 residents in Memory Care and 132 residents in Independent Living. On today's date, LPA inspected the six (6) domains including: Infection Control, Operational Requirements, Resident Rights/Information, Planned Activities, Food Services, and Disaster Preparedness. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility has a updated Infection Control Plan in place. Staff are adhering to infection control requirements. The facility allows visitors, such as ombudsman and advocacy representatives, to see residents privately at reasonable hours and without prior notice. Operational Requirements: A fire clearance is in place. The Infection Control Plan is in place. Hospice Waiver for six (6) is approved and there are six (6) residents receiving hospice care, and zero (0) bedridden. Fire Drill was last conducted on 03/12/2026. Valid Liability Insurance is in place. Residents Rights/Information: The required information such as Personal rights of residents, Emergency Exiting Floor Plan, Ombudsman information, Complaint poster, Rights of Resident Councils, Visiting policy, Theft and loss policy and Emergency Telephone Numbers are posted throughout the facility. The facility has resident rights council who meet regularly. The facility provides internet services to all residents and have access to the facility phone. Planned Activities: The facility provides sufficient space to accommodate both indoor and outdoor activities. The facility offers scheduled activities and an up-to-date calendar is posted in separate buildings. The facility employs a full-time staff (Activity coordinator) to organize, conduct and evaluate planned activities. Food Service: The kitchen was inspected and the food preparation area and storage areas were observed to be clean and sanitary. Sufficient food supply is stored in the kitchen and food storage room consisting of 2-day perishables, 7-day non-perishables, and emergency food supplies. Sanitation practices and cleanliness in the kitchen were observed. Per Director of Wellness, there are no residents with modified diet. Some kitchen staff workers were observed to be using hairnets and disposable gloves while working. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least two (2) relocation sites. Emergency training such as earthquake drill, elopement and evacuation procedures are conducted on a quarterly basis. Evacuation procedures, including emergency exits are included in the facility sketch. The last fire drill was conducted on 03/12/2026. ***Due to time constraints, LPA was not able to complete the annual inspection for this facility. LPA will do a continuation of this inspection at a later date.*** Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies observed during today’s visit. Exit interview was held and a copy of the report was provided to the Director of Wellness Eusebio 'Sev' Tienda.the state’s words, verbatim · CDSS document, May 1, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit. LPA met with Andrew Villegas, Nurse Supervisor and explained the purpose of the visit. Shortly after, LPA met with Jeremiah Hovsepian Bearce, Executive Director and Eusebio 'Sev' Tienda, Director of Wellness who both assisted LPA with the inspection. The facility is licensed to serve (200) non-ambulatory residents age 60 and above. Hospice waiver approved for (6) residents and Memory Care approved for (12) residents. Facility is approved to lock both exterior doors on the perimeter gates in the Memory Care unit (Hacienda Bldg.). Facility is a Continuing Care Retirement Community (CCRC) which includes separate buildings throughout the premises. The Assisted Living residents are located in the Memorial Lodge (ML) and Shu Lodge (SL). Memory Care Unit which is located in the Hacienda Building, is approved for 12 residents. Currently, there are 29 residents in the Assisted Living, 10 residents in Memory Care and 107 residents in Independent Living. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility's Infection Control Plan was recently reviewed and updated on 03/17/2025. Staff are adhering to infection control requirements. The facility allows visitors, such as ombudsman and advocacy representatives to see residents privately at reasonable hours and without prior notice. Operational Requirements: The Infection Control Plan has been included to the Plan of Operation. Hospice Waiver for 6 is approved and there are (6) residents receiving hospice care, (0) bedridden . A fire clearance is in place. Fire Drill was last conducted on 03/13/2025. Liability Insurance is in place and expires on 01/01/2026. Physical Plant & Environment Safety: LPA toured the physical plant areas inside and outside and was accompanied by Andrew Villegas, Nurse Supervisor. The facility is a gated community with multiple single story buildings to accommodate Memory Care, Assisted Living and Independent Living residents, all arranged in a campus-like setting. LPA toured a random selection of resident rooms in the Assisted Living (Memorial lodge and Shu lodge) and Memory Care unit (Hacienda bldg.). Resident rooms were furnished appropriately. Each resident room has their own bathroom. The bathrooms were observed to be clean, operational w/grab bars and have slip-resistant mats. The hot water temperature was tested throughout the facility and measured within Title 22 Regulation guidelines. The facility has central air and heating accommodations. The front grounds of the facility are well landscaped and have a leveled walkway to the entrance. There are various yard areas throughout the facility that are equipped with patio furniture for residents' comfort and safety. There are smoke detectors, carbon monoxide detectors and an emergency sprinkler system throughout the facility are operational and compliant. The fire extinguishers were observed throughout the facility and are fully charged. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. ***CONTINUED ON LIC-809-C*** Staffing: Facility employs a sufficient number of staff including night staff that are trained and able to provide care and supervision to the residents in the event of an emergency. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility. Personnel Records-Training: LPA reviewed staff files and verified health screenings, criminal records and fingerprint clearances. Personnel files include documentation of staff training in areas like medication assistance, postural supports, Alzheimer’s and Dementia care, health clearance, vaccinations, and 1st Aid/CPR. Administrator, Andrew Smith's certificate is valid and expires on 02/11/2027. Residents Rights-Information: The required information such as Personal rights of residents, Emergency Exiting Floor Plan, Ombudsman information, Complaint poster, Rights of Resident Councils, Visiting policy, Theft and loss policy and Emergency Telephone Numbers are posted throughout the facility. The facility has resident rights council who meet regularly. The facility provides internet services to all residents and have access to the facility phone. Planned Activities: The facility provides sufficient space to accommodate both indoor and outdoor activities. The facility offers scheduled activities and an up to date calendar is posted in separate buildings. The facility employs a full-time staff (Activity coordinator) to organize, conduct and evaluate planned activities. Food Service: Sufficient food supply is stored in the kitchen and food storage room consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Sanitation practices and cleanliness in the kitchen were observed. Some kitchen staff workers were observed to be using hairnets and disposable gloves while working. Incidental Medical & Dental: Medications are centrally stored and properly labeled in their original containers or bubble packs. Facility has (2) medical carts and uses eMar called point-click care to document residents medications. A complete first aid kit is maintained in the medication room. Memory Care and Assisted Living have their own medication room. LPA reviewed multiple residents medications in the medication room with no issues observed. Resident Records-Incident Reports: Resident files are maintained in the business office. A total of (10) resident files were reviewed. Resident files contained Admission Agreements, Physician's Reports, Appraisal, TB clearance, Functional Capability Assessment, Physician's Orders, Medical Consent and Medication Records. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers in place. Emergency training such as earthquake drill, elopement and evacuation procedures are conducted on a quarterly basis. Evacuation procedures, including emergency exits are included in the facility sketch. Residents with Special Health Needs: Facility admits residents with dementia and staff files reviewed today all have required training documented. LPA observed 'no smoking oxygen in use' signs posted in some residents' rooms. Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during todays' visit. Exit interview held and a copy of the report was provided to Director of Wellness Eusebio 'Sev' Tienda.the state’s words, verbatim · CDSS document, Apr 21, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tena Herrera conducted the required unannounced annual inspection. LPA met with Director of Wellness Sev Tienda and Director of Business Service Mike Carrasco who assisted with the visit. The facility is licensed to serve a capacity of two hundred (200) Non-ambulatory residents ages 60 and above. There is an approved Hospice Waiver on file for six (6) residents and an approved Dementia Care plan. This is a Continuing Care Retirement Community (CCRC) which includes separate buildings throughout the premises. The Assisted Living residents are located in the Memorial Lodge (ML) and Shu Lodge (SL). Memory Care is approved for 12 residents which is located in the Hacienda Building.Facility is approved to lock both exterior doors on the perimeter gates in the memory care unit/hacienda building. There are currently 34 residents residing in Assisted Living, 10 residents in Memory Care and 132 residents in Independent Living. There is currently one resident on Hospice. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: The facility staff are using appropriate hand hygiene and cleaning/disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan. Operational Requirements: The facility has an approved fire clearance, there is a plan of operation with required Infection Control Plan, Dementia Plan and training and facility maintains the required liability insurance. Physical Plant & Environment Safety: LPA toured facility, a total of multiple residents’ bedrooms/units were checked and had the required closet/drawer space to accommodate each resident comfortably available. There are smoke detectors, carbon monoxide detectors and an emergency sprinkler system throughout the facility that are operable and in compliance. The fire extinguishers were observed throughout the facility and are fully charged. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available. The hot water temperature was tested throughout the facility resident private bathrooms and measured within the required range of 105-120 degrees. There are multiple shaded patio/garden areas for residents. (continued on 809-C) Staffing: There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in care and supervision of the residents in the case of an emergency. Personnel Records-Training: Staff have criminal record clearance, current First-Aid/CPR/AED training along with training in postural supports, Alzheimer’s and Dementia, medication assistance, and other ongoing training are documented in personnel files. LPA reviewed 10 staff files with no issues observed. Administrator Andrew Smith certificate expires on 2/11/2025. Resident Records-Incident Reports: Resident files are kept in a secure location and have the following documents in their files - Pre-admission appraisal/Appraisal Needs & Services Plan, Admission Agreements, Identification & Emergency Information and current Physician's Report. LPA reviewed 10 Resident Files with no issues observed. Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters posted throughout common areas: Residents Rights, Complaint Poster, and Ombudsman. Planned Activities: Facility provides scheduled activities with a monthly calendar and the required full-time staff that conduct and evaluate planned activities. There is sufficient space both indoor and outdoor for activities. Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. Incidental Medical & Dental: Medication is properly labeled and are centrally stored and are in their original containers. Memory Care and Assisted Living have their own medication room, LPA reviewed multiple residents medications in both Medication Rooms with no issues observed. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. The last drill was conducted on 4/22/24. Residents with Special Health Needs: Facility admits residents with dementia and staff files reviewed today all have required training documented. Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during todays visit. Exit interview held and a copy of the report was provided to Director of Wellness Sev Tiendathe state’s words, verbatim · CDSS document, May 10, 2024

Allegation investigated: Residents are being bullied while in care. Staff yell at the residents while in care.

Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit regarding the above allegations. The purpose of the visit was explained to Director of Wellness Sev Tienda. The investigation consisted of the following: On 9/1/2022, a physical plant tour of the assisted living, memory care unit, dining room, and facility grounds was conducted. Staff (S1-S6) and residents (R1-R4) were interviewed. Resident (R1's) file documents [Profile Face Sheet, Preplacement Appraisal Information, Resident Appraisal (1/25/2022), Physician Report (4/3/2019), MD letter (3/1/22), Advance Healthcare Directive, Power of Attorney, Montreal Cognitive Assessments (MOCA), Notice of CCRC Resident Level of Care Transfer, incident report (1/28/22)] were reviewed and obtained, as well as resident rosters, and LIC 500 Personnel Report. During today's, visit LPA toured the Memory Care Unit, the Assisted Living Unit, and interviewed residents (R5- R10). ***Narrative continues next page.*** Unsubstantiated Allegation: Residents are being bullied while in care. It is alleged that the sales team staff were bullying residents into considering a move into the Memory Care Unit. Based on interviews conducted, all eight (8) staff denied the allegation and stated that residents are explained the advantages of living in each of the CCRC areas, as well as level of care services and ultimately it is the resident's choice. According to staff interviews, discussion about the possibility of moving into the Memory Care Unit is based on their annual appraisal and any change in condition. Per staff interviews, if there is a change in condition the Care Team meets and a Care conference is held with resident and family member and/or authorized representative to discuss options. In resident (R1's) case, the resident was temporarily placed in the Bridge Care program per family request due to increased weakness. Staff stated the Director of Wellness assessed R1 based on the level of care needed during their stay in the Bridge Care program. At that time, an updated Physician's Report had not been provided to the facility, therefore the facility administered a MOCA assessment and R1's spouse initially agreed to moving the resident in to the Memory Care unit but backed out. One (1) family member was interviewed and reported that the staff team did not bully them into placing their loved one in the Memory Care Unit. A total of 10 residents were interviewed, and only 2 residents said they felt pressured "bullied" about moving their partners into the Memory Care Unit. The department was unable to obtain evidence to support this allegation. Allegation: Staff yell at the residents while in care. It is alleged that the facility's Sales Representative often screams and yells at residents when approached with questions. A total of eight (8) staff were interviewed of which all denied the allegation. The Sales team staff stated that all residents are treated with dignity and respect and are never yelled at. Sales Representative (S5) stated they do not yell/scream at residents, and that on the contrary residents say to staff the voice tone is too soft spoken. Staff (S5) stated that they do speak in a louder voice tone with hard or hearing residents, and there are some staff that have a naturally louder voice. However, staff stated that they have never yelled at residents (R1 & R2). No staff reported hearing other staff yell at residents. A total of 10 residents were interviewed, of which one (1) resident stated that Sales staff yell at residents. One (1) resident's family member was interviewed and reported no knowledge of the allegation, and stated that they have observed good staff treatment towards residents. There is insufficient evidence to corroborate the allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted with Wellness Director Sev Tienda and a copy of the report was issued.the state’s words, verbatim · CDSS document, Mar 8, 2024 · control 28-AS-20220826104506

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced Case Management. LPA met with Sev Tienda and explained the purpose for the visit. Today's visit is to observe the delayed egress system and the two exit doors that have been approved to remain locked per the Approved Fire Safety Request (STD850) dated 6/1/21. Details on this approval state,"FACILITY IS LICENSED TO SERVE 200. NON-AMBULATORY RESIDENTS AGE 60 AND ABOVE. HOSPICE WAIVER APPROVED FOR 6 RESIDENTS. MEMORY CARE UNIT APPROVED FOR 12 RESIDENTS. FACILITY IS APPROVED TO LOCK BOTH EXTERIOR DOORS ON THE PERIMETER GATES IN THE MEMORY CARE UNIT/ HACIENDA BUILDING", with a special comment by the approving inspector Smith stating "approved to lock/secure 2 exit gates". There are currently 10 Residents in the Memory Care/Support Unit "Hacienda Building". Delayed egress system was tested and is working. All walkways around the Memory Care/Support Unit "Hacienda Building" unit were clear of hazards. The facility has 3 entrance/exits that lead to the front of the Hacienda Building, and 2 exits that lead to the back patio. The gates that will be locked/secured are the metal gates in the exterior of the building that wrap around the back yard/patio area. There is one gate on each side of the building. These gates are secured with a metal or rubber wire and are able to be opened by staff in the case of an emergency. There were no deficiencies cited on today's visit. Exit interview and copy of report and license has been provided to Wellness Director Sev Tiendathe state’s words, verbatim · CDSS document, Feb 9, 2024