191603205-2-9-2023-11-AS-AINZ-CNW23Z-20230209160310

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191603205
Report Date: 02/09/2023
Date Signed: 02/09/2023 04:03:31 PM

Document Has Been Signed on 02/09/2023 04:03 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
EL SEGUNDO, 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:	02/09/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:32 PM
MET WITH:	Robert Aguilas and Serenia Espiritu		TIME COMPLETED:	04:00 PM

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On 2/9/23 LPM Eva Alvarez and LPA Alfonso Iniguez conducted an unannounced Annual required visit at this facility. LPM and LPA were met by Robert Aguilos (Administrator) and Sorenia Espiritu (Director of Nursing). The purpose of today’s visit was explained.

There are currently (36) residents residing in the facility. There are (26) ambulatory and (10) non-ambulatory residents who are occupying private rooms. The facility is a (3) floor building and consists of (62) bedrooms, (65) bathrooms, commercial kitchen, large dining room, auditorium, storage areas, nursing stations, activities rooms, exercise room, recreation room, medical supply room, craft room, gift shop, conference rooms, shaded patio area, side court yard, patio, and laundry rooms.

LPM and LPA toured the facility, and observed the 1st floor bedrooms are occupied by residents. the 2nd and 3rd rd floors are currently vacant. The medication are stored in a central location and inaccessible to residents. Resident records are electronically filed. LPM and LPA toured the commercial kitchen and observed sufficient supply of perishable and nonperishable foods, the hot water temperature tested at 109 -120 F in areas where food is prepared. LPM and LPA observed linens , bath towels, and personal hygiene supplies. The fire extinguishers on 1st and ground floors are fully charge. The facility last smoke alarm and carbon monoxide test was conducted by Fire Safety Service on 1/20/2023. The test report was provided and reviewed during this visit. There are no concerns reported by Fire Safety Service.

The entrance, exits, and passageways are free from obstructions. Carbon monoxide detector was observed in kitchen area.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023

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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: JEANNE JUGAN RESIDENCE	FACILITY NUMBER: 191603205
	VISIT DATE: 02/09/2023

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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.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023

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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: JEANNE JUGAN RESIDENCE	FACILITY NUMBER: 191603205
	VISIT DATE: 02/09/2023

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During the visit, LPM and LPA observed the facilities screening system that includes a hands free temporal thermometer, sign-in log, and sanitation station. Sanitation stations throughout facility are visible. LPM and LPA observed staff and residents wearing masks, required postings are visible. The facility Mitigation Plan was approved by CCL 7/27/2021. A 30 day supply of PPE's are in stock.

No citations were issued during this visit. An exit interview was conducted with Robert Aguilos and Soreina Espiritu and copy of this report was provided.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023

LIC809 (FAS) - (06/04)

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