Citations (last 6 years)
Citations (over 6 years)
2.7 citations/year
Citations are regulatory findings recorded during state inspections.
33% better than California average
California average: 4 citations/yearCitations per year
8
6
4
2
0
Occupancy
Latest occupancy rate
66% occupied
Based on a February 2026 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Annual Inspection
Census: 345
Capacity: 520
Citations: 0
Date: Feb 12, 2026
Visit Reason
The visit was an unannounced Annual Continuation Visit conducted by the Licensing Program Analyst to evaluate compliance with licensing requirements at the facility.
Findings
The facility was found to be clean, well-maintained, and in compliance with regulations. No deficiencies were cited during the inspection. Safety equipment such as fire extinguishers, alarms, and carbon monoxide detectors were tested and found operational. Resident rooms and common areas were inspected and found compliant.
Report Facts
Resident rooms inspected: 17
Facility kitchens: 3
Fire extinguisher last serviced: 2025
Fire department last inspection: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Frempong | Director | Met with Licensing Program Analyst during inspection and participated in exit interview |
| Mayra Cota | Licensing Program Analyst | Conducted the unannounced Annual Continuation Visit |
| Lindsay Mullen | Assistant Director | Facilitated the inspection visit and participated in exit interview |
Inspection Report
Annual Inspection
Census: 345
Capacity: 520
Citations: 0
Date: Feb 10, 2026
Visit Reason
The inspection was an unannounced required annual visit conducted by the Licensing Program Analyst to evaluate compliance with licensing requirements at the facility.
Findings
The Licensing Program Analyst reviewed resident and staff files, emergency preparedness plans, safety drill logs, medication administration, and conducted staff interviews. No deficiencies were cited during this visit.
Report Facts
Resident files reviewed: 15
Staff files reviewed: 12
Residents medication reviewed: 10
Staff interviewed: 5
Facility capacity: 520
Facility census: 345
Disaster/Fire drills frequency: 4
Last fire drill date: Nov 28, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Frempong | Director | Met with Licensing Program Analyst during inspection and participated in exit interview |
| Lindsay Mullen | Assistant Director | Facilitated the visit and participated in exit interview |
| Mayra Cota | Licensing Program Analyst | Conducted the inspection visit |
| Wei Siew Ho | Licensing Program Manager | Named in report header and signature section |
Inspection Report
Citations: 4
Date: May 30, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, safety, and documentation at Mount San Antonio Gardens nursing home.
Findings
The facility was found deficient in multiple areas including failure to promptly notify a physician of a resident's change of condition, inadequate perineal care leading to risk of urinary tract infections, improper use and documentation of bed side rails, and inaccurate documentation related to side rail assessments and consents. These deficiencies posed potential risks of harm to residents.
Citations (4)
Failure to promptly notify the physician of Resident 15's change of condition on 5/28/2025.
Failure to provide adequate perineal care for Resident 9, risking urinary tract infections.
Failure to complete a side rail assessment aligned with the physician's order for Resident 8 and failure to obtain accurate side rail consent.
Failure to ensure accurate documentation for the use of side rails for Resident 8, including discrepancies between assessment, consent, and physician's order.
Report Facts
Date of Resident 15's Change of Condition: May 28, 2025
Medication dosage: 750
Medication dosage: 16
Admission date: Jan 18, 2020
Admission date: Jul 6, 2017
Admission date: Jan 18, 2018
MDS date: May 5, 2025
MDS date: Apr 9, 2025
MDS date: Mar 25, 2025
Side Rail Assessment date: Mar 24, 2025
Physician's order date: Apr 8, 2025
Side Rail Consent Form date: Apr 8, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 1 | Licensed Vocational Nurse | Named in failure to notify physician promptly of Resident 15's change of condition and side rail assessment and consent discrepancies for Resident 8. |
| CNA 2 | Certified Nursing Assistant | Observed Resident 15's condition and notified LVN 1 on 5/28/2025. |
| RN 1 | Registered Nurse | Provided information on respiratory distress signs and proper notification procedures. |
| AA | Activities Assistant | Provided information on Resident 15's daily routine. |
| Director of Nursing | Director of Nursing | Provided statements on policy requirements for change of condition reporting and side rail assessments and consents. |
| CNA 1 | Certified Nursing Assistant | Performed perineal care for Resident 9. |
Inspection Report
Census: 437
Capacity: 520
Citations: 0
Date: 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
Citations: 0
Date: 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
Citations: 0
Date: 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 residents having hot coffee spilled on them due to coffee cup lids not fitting properly.
Complaint Details
The complaint alleged that staff did not ensure a safe environment in the dining room due to coffee cup lids not fitting properly, causing hot coffee spills on residents. The allegation was unsubstantiated after investigation.
Findings
The investigation included interviews with residents and staff and a tour of the dining room. All interviewed residents and staff reported feeling safe and no incidents of coffee spills were observed or reported. The facility had recently replaced coffee cup lids after becoming aware of the issue. The allegation was determined to be unsubstantiated due to lack of evidence.
Report Facts
Capacity: 520
Census: 452
Residents interviewed: 8
Staff interviewed: 6
Days since lid replacement: 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 Licensing Program Analyst during investigation |
| Tony Vasallo | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Citations: 4
Date: May 16, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, infection control, food safety, and other facility operations at Mount San Antonio Gardens.
Findings
The facility was found deficient in multiple areas including inaccurate elopement risk assessment for a resident, inadequate treatment and monitoring of a resident's skin tear and edema, failure to follow safe food storage and labeling practices, and improper infection control related to dirty laundry handling. These deficiencies posed potential risks for resident harm, infection transmission, and compromised quality of care.
Citations (4)
Failed to ensure one sampled resident was accurately assessed for elopement risk.
Failed to provide appropriate treatment and care for a resident's skin tear and edema, resulting in no improvement and potential physical decline.
Failed to follow safe and proper food storage practices by not labeling or dating food items in the kitchen.
Failed to implement infection control practices by improperly storing dirty laundry on a toilet seat, risking cross contamination.
Report Facts
Dates of elopement attempts: 2
Dates of physician orders for skin care: 1
Number of unlabeled food items observed: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse 1 | Registered Nurse | Stated Resident 23 was an elopement risk and acknowledged failure to carry out physician order for geri sleeves for Resident 12. |
| Director of Nursing | Director of Nursing | Stated the elopement assessment for Resident 23 was incorrect and confirmed incidents of elopement. |
| Personal Caregiver | Personal Caregiver | Reported noticing Resident 12's edema two weeks prior to observation. |
| Quality Assurance Nurse | Quality Assurance Nurse | Reviewed Resident 12's physician orders and observed lack of geri sleeves on Resident 12. |
| Assistant Director of Nursing | Assistant Director of Nursing | Reviewed medical records and stated skin assessment was not done for Resident 12's worsening skin tear. |
| Certified Nursing Assistant 1 | Certified Nursing Assistant | Reported hospice staff left dirty laundry on toilet seat instead of placing it in dirty linen barrel. |
| Infection Preventionist Nurse | Infection Preventionist Nurse | Stated hospice staff should not leave dirty laundry on toilet seat due to contamination risk. |
| Purchasing Clerk | Purchasing Clerk | Observed unlabeled food items and stated importance of labeling to prevent expired food use. |
| Cold Food Prep | Cold Food Prep | Stated food items were labeled with arrival dates to prevent serving expired food. |
Inspection Report
Annual Inspection
Census: 380
Capacity: 520
Citations: 0
Date: Jan 25, 2024
Visit Reason
The inspection was a subsequent annual inspection visit conducted as part of case management and annual continuation to assess compliance with regulatory standards.
Findings
The facility was found to have operable carbon monoxide detectors, fire extinguishers properly serviced and checked, signal systems tested and operational, hot water temperatures within regulations, and adequate safety features in bathrooms. Food service areas were clean with proper food storage and pest control. Medications were stored securely and administered as prescribed with proper documentation.
Report Facts
Fire extinguisher last serviced: 2023
Fire extinguisher last checked: 2024
Hot water temperature: 111
Hot water temperature: 117
Hot water temperature: 109
Hot water temperature: 115
Hot water temperature: 112
Hot water temperature: 113
Food supply duration: 2
Food supply duration: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Frempong | Administrator | Facility administrator present during inspection and exit interview |
| Elizabeth Irra | Licensing Program Analyst | Conducted the annual inspection visit |
| Lindsay Mullen | Met with Licensing Program Analyst during inspection | |
| Tony Vasallo | Supervisor | Supervisor named in report |
Inspection Report
Annual Inspection
Census: 380
Capacity: 520
Citations: 0
Date: 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
Citations: 0
Date: 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
Citations: 0
Date: Nov 20, 2023
Visit Reason
The visit was an unannounced complaint investigation 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.
Complaint Details
The complaint was unsubstantiated after interviews with staff and residents, file reviews, and observations. It was determined that the resident did not require a higher level of care and was receiving proper nutrition and care as per facility protocols.
Findings
The investigation found insufficient evidence to substantiate the allegations. Staff and residents interviewed denied the claims, and observations and file reviews supported that the resident's needs were being met appropriately within the assisted living portion of the facility.
Report Facts
Capacity: 520
Census: 399
Staff interviewed: 6
Residents interviewed: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Frempong | Administrator | Met with Licensing Program Analyst during the complaint investigation |
| Jose Villalobos | Licensing Program Analyst | Conducted the complaint investigation visit |
| Fernando Fierros | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Routine
Citations: 8
Date: May 26, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident dignity, care, safety, medication administration, infection control, and other aspects of facility operations.
Findings
The facility was found deficient in multiple areas including failure to ensure resident privacy and dignity, inadequate accommodation of resident needs, incorrect pressure ulcer care, failure to maintain range of motion and mobility programs, inadequate respiratory care, high medication error rate, improper meal portioning, and lapses in infection prevention and control practices.
Citations (8)
Failed to ensure privacy and a dignified environment for two sampled residents as privacy curtains were not closed during toileting.
Failed to provide adequate furnishing to accommodate use of personal computer for a resident whose desk broke.
Failed to ensure correct low air loss mattress setting was used per resident's weight, risking pressure injury development.
Failed to provide services to maintain mobility and range of motion for two residents with limited ROM and mobility.
Failed to ensure adequate supply of oxygen in a resident's portable oxygen cylinder tank.
Medication error rate exceeded 5% with 8 errors in 28 opportunities; medications were administered late.
Failed to ensure appropriate serving utensils were used for smaller meal portions requested by a resident.
Failed to implement infection prevention and control program adequately including hand hygiene lapses, improper handling of soiled laundry, and improper drying of resident's stockings.
Report Facts
Medication errors: 8
Medication administration opportunities: 28
Medication error rate: 28.57
Oxygen flow rate: 2
Oxygen flow rate: 3
LAL mattress setting incorrect: 250
LAL mattress setting correct: 165
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse 2 | LVN | Stated privacy was important to protect resident's dignity and self-respect |
| Licensed Vocational Nurse 1 | LVN | Stated privacy curtains must be closed when changing residents |
| CNA 1 | Certified Nursing Assistant | Observed removing resident's pants without closing privacy curtain |
| CNA 5 | Certified Nursing Assistant | Observed assisting resident without closing privacy curtain or door |
| Director of Nursing | DON | Stated importance of correct LAL mattress setting and oxygen tank checks |
| Licensed Vocational Nurse 3 | LVN | Stated LAL mattress setting was incorrect for Resident 6 |
| Director of Rehabilitation | DOR | Reviewed OT discharge summary and noted missing Rehabilitation Screening Forms |
| Restorative Nursing Aide 2 | RNA | Reported resident unable to perform sit to stand exercises due to pain |
| Licensed Vocational Nurse 3 | LVN | Administered medications late to Resident 30 |
| Assistant Director of Nursing | ADON | Stated importance of timely medication administration |
| Dietary Services Supervisor | DSS | Used same size scoops for smaller meal portions instead of appropriate utensils |
| Registered Dietician | RD | Stated smaller portions require use of different size serving utensils per policy |
| Laundry Aide 1 | LA | Observed soiled laundry baskets uncovered in laundry room |
| Infection Preventionist Nurse | IPN | Noted infection control lapses with laundry and resident stockings |
| Certified Nursing Assistant 1 | CNA | Failed to perform hand hygiene before resident care |
| Certified Nursing Assistant 2 | CNA | Failed to perform hand hygiene before resident care |
Inspection Report
Annual Inspection
Census: 76
Capacity: 520
Citations: 0
Date: Dec 9, 2022
Visit Reason
Licensing Program Analyst Elizabeth Irra conducted an unannounced Required-1 year visit focusing on COVID-19 Infection Control Practices at Mount San Antonio Gardens.
Findings
COVID-19 infection control practices including signage and PPE supplies were observed throughout the facility. Medication was reviewed for seven residents. Most residents and all staff were fully vaccinated. Adequate food supplies and staff mask usage were also observed.
Report Facts
Resident vaccination count: 75
Resident vaccination count: 1
Medication review count: 7
Facility capacity: 520
Current census: 76
Unit capacities and census: 70
Unit capacities and census: 58
Unit capacities and census: 10
Unit capacities and census: 10
Unit capacities and census: 10
Unit capacities and 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 |
| Tony Vasallo | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Census: 7
Capacity: 520
Citations: 0
Date: 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
Citations: 0
Date: 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
Citations: 0
Date: Dec 20, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility was experiencing financial hardship affecting residents while in care.
Complaint Details
The complaint alleged financial hardship for residents and concerns about the management and solvency of the Homeship Fund. The complaint was unsubstantiated based on interviews and financial document review.
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 was determined to be unsubstantiated after review of financial statements and interviews with the complainant and facility executive director.
Report Facts
Facility capacity: 520
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Houston | Financial Analyst | Conducted interviews and investigation related to the complaint |
| Maureen Beith | Executive Director | Interviewed during investigation regarding financial allegations |
| Joyce Frempong | Administrator | Named as facility administrator |
Inspection Report
Capacity: 520
Citations: 0
Date: Sep 13, 2021
Visit Reason
The Licensing Program Analyst conducted an announced walk-through visit to evaluate the Taylor Villa location, previously a skilled nursing facility, now intended 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 detectors, fire extinguishers, and signal systems. Cleaning supplies and sharps were properly secured, and the physical plant and resident rooms met regulatory standards. Adequate linens, furniture, and PPE supplies were observed, and emergency plans and COVID-19 signage were posted.
Report Facts
Fire extinguishers: 3
Non-ambulatory beds: 10
Hot water temperature: 116
Day supply of perishables: 2
Day supply of non-perishables: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Irra | Licensing Program Analyst | Conducted the announced visit and evaluation |
| Joyce Frempong | Administrator | Facility administrator named in the report |
| Christine Yee | Supervisor | Supervisor overseeing the licensing evaluation |
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