191603205-3-2-2022-11-AS-ASOO-CC528E-20220301161014

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191603205
Report Date: 03/01/2022
Date Signed: 03/02/2022 02:22:38 PM

Document Has Been Signed on 03/02/2022 02:22 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	JEANNE JUGAN RESIDENCE		FACILITY NUMBER:	191603205
ADMINISTRATOR:	SISTER PAUL MAGYAR		FACILITY TYPE:	740
ADDRESS:	2100 SOUTH WESTERN AVENUE		TELEPHONE:	(310) 548-0625
CITY:	SAN PEDRO	STATE: CA	ZIP CODE:	90732
CAPACITY:	62	CENSUS: 36	DATE:	03/01/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:05 AM
MET WITH:	Sorenia Espiritu, Director of Nursing		TIME COMPLETED:	04:15 PM

NARRATIVE

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Licensing Program Analyst (LPA's) Ana Soto and Jeremiah Randle conducted an unannounced Annual required and infection control visit to the above facility. LPA's were met by Sister Coltilde, Manager and later met with Sorenia Espiritu, Director of Nursing and the purpose of today’s visit was explained.

There are currently (36) residents in the facility. (32) residents are ambulatory and (4) are non-ambulatory. The facility is a 3 story commercial building located in a residential neighborhood. It consists (62) bedrooms, (65) bathrooms, medical wing in the 2nd flr, kitchen, dining room, auditorium, storage areas, salon, nursing station, oxygen room, weight room, activities room, ocean room, recreation room, medical supply room, craft room, activities room, gift shop, conference rooms, shaded back yard, side court yard, patio, parking lot, and separated laundry building.

LPA's and Sorenia toured the entire facility inside and out and inspected rooms 101 - 148. Room #118 has tub faucet leaking. Documents are posted as mandated. 1st Floor Bedrooms are occupied by residents and contain the mandated furniture. 2nd Flr is the skilled nursing floor and where the PPE's are stored. 3rd Floor is empty no residents reside there. The (65) bathrooms are clean and operational. First aid kit is fully stocked with manual, smoke detectors and carbon monoxide detector are inter-connected and were in compliance and operational. No firearms are stored at facility and there is a fountain in the courtyard does not present a hazard for residents. Medications are stored, locked and inaccessible to residents. 3 Residents files and medications are current. 3 Staff files are current. Ample supply of perishable and nonperishable food, hot water temperature is 114.3 degrees Fahrenheit, linens and personal hygiene supplies are adequate, hazardous toxins and/or sharp items are inaccessible to residents, 4 fire extinguisher were fully charge. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. The facility is in good repair.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: JEANNE JUGAN RESIDENCE	FACILITY NUMBER: 191603205
	VISIT DATE: 03/01/2022

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During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing stations in the front lobby and 1st floor. Sanitation carts were visible in the 1st floor. The visitors are logged and temperature checked, Sanitizer/soap in the bathrooms and resident bathrooms. Additional sanitation supplies are locked in the 2nd floor storage room along with the rest of the PPE's supplies. LPA observed staff and residents wearing masks, resident private rooms will be converted to isolation rooms (if needed) and required postings throughout the facility. The residents temperature's are checked and logged once a day. PPE's are enough for 30 days.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiency and issued a citation.

An exit interview was conducted with Sorenia Espiritu, Director of Nursing and a copy of Report and Appeal Rights provided

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 03/02/2022 02:22 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: JEANNE JUGAN RESIDENCE	FACILITY NUMBER: 191603205
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited


	Deficient Practice Statement
1 2 3 4	87303(e)(6) - Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs. This was not met as evidenced by: Based on interviews and records room 118 had leaking bath tub faucet which could pose a health and safety risk for residents.
	POC Due Date: 03/15/2022
	Plan of Correction
1 2 3 4	The administrator will send a picture showing faucet fixed, no longer leaking to LPA by email, text. or fax by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022

LIC809 (FAS) - (06/04)

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