Inspection Report Summary
Most inspections of this facility found no deficiencies, with the most recent report from February 4, 2025, showing no issues after interviews and an exit meeting. Several complaint investigations, including those in November 2023 and June 2024, were unsubstantiated, indicating concerns raised were not supported by evidence. The facility consistently met standards for infection control, staffing, resident rights, and environmental safety across multiple annual inspections. No fines, enforcement actions, or severe deficiencies were noted in the available reports. The overall record shows a stable compliance history with no recent problems.
Deficiencies per Year
4
3
2
1
0
Census Over Time
Census
Capacity
Inspection Report
Census: 437
Capacity: 520
Deficiencies: 0
Feb 4, 2025
Visit Reason
The visit was an unannounced collateral visit to conduct interviews with 6 residents regarding an incident that occurred at the residents' previous facility.
Findings
Licensing Program Analyst Mary Flores conducted interviews with residents and met with the facility administrator. An exit interview was conducted and a copy of the report was provided.
Report Facts
Number of residents interviewed: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Flores | Licensing Program Analyst | Conducted the unannounced collateral visit and interviews |
| Joyce Frempong | Administrator | Met with Licensing Program Analyst during the visit |
Inspection Report
Annual Inspection
Census: 427
Capacity: 520
Deficiencies: 0
Dec 6, 2024
Visit Reason
The inspection was an annual unannounced comprehensive inspection conducted by Licensing Program Analysts to assess compliance with regulatory requirements at Mount San Antonio Gardens, a Continuing Care Retirement Community.
Findings
The facility was found to be adhering to operational, staffing, and infection control requirements. Resident records, rights, planned activities, disaster preparedness, and physical plant safety measures were reviewed and found compliant. Food service and environmental safety standards were also met.
Report Facts
Resident census: 427
Total capacity: 520
Capacity by unit: 70
Capacity by unit: 10
Capacity by unit: 10
Current residents by unit: 62
Current residents by unit: 10
Current residents by unit: 10
Independent Living residents: 345
Fire extinguisher last serviced: 202401
Fire extinguisher last checked: Dec 3, 2024
Last fire drill date: Nov 26, 2024
Food supply duration: 2
Food supply duration: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Frempong | Director of Assisted Living | Facility Director present during inspection |
| Lindsay Mullen | Assistant Director | Met with Licensing Program Analysts during inspection |
| Mayra Cota | Licensing Program Analyst | Conducted the inspection |
| Elizabeth Irra | Licensing Program Analyst | Conducted the inspection |
| Luis De Leon | Licensing Program Analyst | Conducted the inspection |
| Wei Siew Ho | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 452
Capacity: 520
Deficiencies: 0
Jun 11, 2024
Visit Reason
An unannounced complaint investigation visit was conducted regarding an allegation that staff did not ensure a safe environment in the dining room, specifically concerning hot coffee spills due to improperly fitting coffee cup lids.
Findings
The investigation found that staff placed lids properly on coffee cups and interviews with 8 residents and 6 staff indicated no observed incidents of coffee spills or safety concerns. The distributor recently changed coffee cups, and new lids were ordered within 24 hours of identifying the issue. The allegation was unsubstantiated due to lack of evidence.
Complaint Details
The complaint alleged unsafe environment in the dining room due to coffee cup lids not fitting properly, causing hot coffee spills. The allegation was unsubstantiated after investigation.
Report Facts
Residents interviewed: 8
Staff interviewed: 6
Days since cup/lid change: 7
Hours to order new lids: 24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the complaint investigation visit |
| Joyce Frempong | Administrator | Facility administrator met with investigator and participated in exit interview |
| Tony Vasallo | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 380
Capacity: 520
Deficiencies: 0
Jan 25, 2024
Visit Reason
Licensing Program Analysts conducted a subsequent annual inspection visit as part of case management and annual continuation to evaluate compliance with regulatory requirements.
Findings
The inspection found that the physical plant and environment safety measures were in place, including operable carbon monoxide detectors and fire extinguishers. Food service areas were clean and properly stocked, and medications were stored securely and administered as prescribed.
Report Facts
Hot water temperature: 111
Hot water temperature: 117
Hot water temperature: 109
Hot water temperature: 115
Hot water temperature: 112
Hot water temperature: 113
Fire extinguisher last serviced: Jan 23, 2023
Fire extinguisher last checked: Jan 2, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Frempong | Administrator | Facility administrator present during inspection |
| Lindsay Mullen | Met with Licensing Program Analyst during inspection | |
| Elizabeth Irra | Licensing Program Analyst | Conducted the inspection visit |
| Tony Vasallo | Named in exit interview and report |
Inspection Report
Annual Inspection
Census: 380
Capacity: 520
Deficiencies: 0
Jan 23, 2024
Visit Reason
Licensing Program Analysts conducted a subsequent annual inspection visit to evaluate compliance with regulatory requirements at the Continuing Care Retirement Community.
Findings
The facility was found to have an Infection Control Plan in place and was adhering to operational and staffing requirements. Staff files were reviewed and found to be current with required certifications and training. Resident records and rights were maintained appropriately. Some domains such as Physical Plant & Environment Safety, Food Service, and Health Related Services remain pending.
Report Facts
Capacity: 520
Census: 380
Sub-unit capacities and census: 70
Sub-unit census: 55
Sub-unit capacities and census: 10
Sub-unit capacities and census: 10
Sub-unit census: 9
Sub-unit census: 306
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Frempong | Administrator | Facility Administrator met with Licensing Program Analysts during the inspection |
| Elizabeth Irra | Licensing Program Analyst | Conducted the annual inspection visit |
| Tony Vasallo | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Census: 402
Capacity: 520
Deficiencies: 0
Dec 21, 2023
Visit Reason
The Licensing Program Analyst conducted an announced visit to inspect the newly developed building located within the campus as part of a Case Management - Licensee Initiated visit.
Findings
The inspection included a tour of a new three-floor building with 53 independent living units. All units were found to have appropriate amenities and safety features, including grab bars in bathrooms and a signal system for daily check-ins. Fire extinguishers were observed and recently serviced. No deficiencies were noted during the inspection.
Report Facts
Assisted Living Census: 76
Independent Living Census: 326
Total Census: 402
Facility Capacity: 520
Number of Independent Living Units: 53
Fire Extinguisher Last Service Date: Nov 20, 2023
Fire Department Clearance Date: Dec 7, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Frempong | Director of Residential Health Services/RFCE Administrator | Met during inspection and received copy of report |
| Patricia Williams | CEO | Met during inspection |
| Ariana Villapudua | Director of Admissions | Met during inspection |
| Elizabeth Irra | Licensing Program Analyst | Conducted the inspection visit |
Inspection Report
Complaint Investigation
Census: 399
Capacity: 520
Deficiencies: 0
Nov 20, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that the facility was retaining a resident with a higher level of care needs and that staff were not ensuring the resident was eating properly.
Findings
The investigation included interviews with staff and residents, file reviews, and observations. There was insufficient evidence to substantiate the allegations regarding the resident's level of care needs and eating habits. The allegations were determined to be unsubstantiated.
Complaint Details
The complaint involved two allegations: 1) the facility retaining a resident with a higher level of care needs, and 2) staff not ensuring the resident was eating properly. Both allegations were found to be unsubstantiated based on interviews, observations, and file reviews.
Report Facts
Staff interviewed: 6
Residents interviewed: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jose Villalobos | Licensing Program Analyst | Conducted the complaint investigation visit |
| Joyce Frempong | Administrator | Facility administrator met during the investigation |
| Fernando Fierros | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 76
Capacity: 520
Deficiencies: 0
Dec 9, 2022
Visit Reason
An unannounced Required-1 year visit focusing on COVID-19 Infection Control Practices was conducted to evaluate compliance with infection control protocols.
Findings
COVID-19 infection control practices including signage, PPE supplies, and staff mask usage were observed throughout the facility. Medication was reviewed for seven residents, and vaccination status was reported with most residents and all staff fully vaccinated.
Report Facts
Resident vaccination count: 75
Resident vaccination count: 1
Medication review count: 7
Facility capacity: 520
Resident census: 76
Unit capacities and census: 70
Unit census: 58
Unit capacities and census: 10
Unit capacities and census: 10
Unit census: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Irra | Licensing Program Analyst | Conducted the inspection visit |
| Ariana Villapudua | Assistant Director | Met with Licensing Program Analyst during inspection |
| Joyce Frempong | Administrator | Facility administrator named in report header |
Inspection Report
Census: 7
Capacity: 520
Deficiencies: 0
Nov 10, 2022
Visit Reason
The visit was a case management walk-through initiated by the licensee to evaluate the Harrison Villa building, a Skilled Nursing Facility licensed location.
Findings
The inspection found that fire alarms, extinguishers, signal systems, and carbon monoxide detectors were tested and operable. The facility was clean, well-maintained, and free from hazards, with appropriate resident accommodations and supplies observed. No deficiencies or violations were noted.
Report Facts
Fire extinguishers: 3
Fire inspection clearance beds: 10
Hot water temperature: 116.7
Hot water temperature: 118.6
Hot water temperature: 115.5
Perishable food supply: 2
Non-perishable food supply: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Irra | Licensing Program Analyst | Conducted the inspection and evaluation visit |
| Joyce Frempong | Administrator | Facility administrator present during the visit |
| Lisa Atilano | Facility representative present during the visit | |
| Tony Vasallo | Supervisor | Supervisor named in the report |
Inspection Report
Annual Inspection
Census: 76
Capacity: 520
Deficiencies: 0
Feb 3, 2022
Visit Reason
Licensing Program Analyst Elizabeth Irra conducted an unannounced Required-1 year visit focusing on COVID-19 Infection Control Practices at the Continuing Care Retirement Community.
Findings
COVID-19 Infection Control Practices were observed throughout the facility including signage, PPE supplies, and social distancing. Residents and staff vaccination status was reviewed, with most fully vaccinated and some pending boosters. Sufficient food supplies were noted and medication was reviewed for select residents.
Report Facts
Resident census: 76
Facility capacity: 520
Residents at Oak Tree Lodge: 67
Capacity of Oak Tree Lodge: 70
Residents at Memory Care: 9
Capacity of Memory Care: 10
Staff pending booster: 31
Residents pending booster: 2
Staff with religious exemption: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Irra | Licensing Program Analyst | Conducted the inspection and met with facility staff |
| Joyce Frempong | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Capacity: 520
Deficiencies: 0
Dec 20, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2021-11-08 regarding financial hardship concerns for residents while in care at Mount San Antonio Gardens.
Findings
The investigation found no indication that the facility was at risk of insolvency or mismanaging the Homeship Fund set up to assist residents. The allegation of financial hardship was unsubstantiated.
Complaint Details
The complaint alleged that the facility was experiencing financial hardship affecting residents. The complaint was investigated through interviews and financial document review and was found to be unsubstantiated.
Report Facts
Facility capacity: 520
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Houston | Financial Analyst / Licensing Program Analyst | Conducted interviews and investigation related to the complaint |
| Maureen Beith | Executive Director | Interviewed during investigation regarding financial allegations |
| Allison Nakatomi | Licensing Program Manager | Oversaw complaint investigation report |
Inspection Report
Capacity: 520
Deficiencies: 0
Sep 13, 2021
Visit Reason
The visit was a Case Management - Licensee Initiated announced walk-through to evaluate the Taylor Villa location, previously a skilled nursing facility, for its readiness to provide care and supervision for 10 non-ambulatory Memory Care residents aged 60 and above.
Findings
The facility was found to be in good repair with operational safety equipment including smoke detectors, carbon monoxide detector, fire extinguishers, and signal system. The physical plant and grounds were free from hazards, and resident rooms and common areas were adequately furnished and maintained. COVID-19 signage and PPE supplies were observed, and emergency and complaint procedures were posted.
Report Facts
Fire Inspection clearance beds: 10
Fire extinguishers: 3
Hot water temperature: 116
Total capacity: 520
Census: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Irra | Licensing Program Analyst | Conducted the announced visit and evaluation |
| Christine Yee | Supervisor | Supervised the licensing evaluation |
| Joyce Frempong | Administrator | Facility administrator mentioned in the report |
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