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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191800633
Report Date: 08/18/2021
Date Signed: 08/18/2021 01:53:28 PM

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:ST JOHN OF GOD RESIDENCEFACILITY NUMBER:
191800633
ADMINISTRATOR:SABRINA TUCKERFACILITY TYPE:
740
ADDRESS:2468 SO. ST. ANDREWS PLACETELEPHONE:
(323) 731-0641
CITY:LOS ANGELESSTATE: CAZIP CODE:
90018
CAPACITY:40CENSUS: 13DATE:
08/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jennifer Pineda/ Sabrina TuckerTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Jade Jordan conducted a facility visit for an annual Inspection, with an Emphasis on Inspection Control. Upon Arrival LPA was screened for Covid 19 symptoms at the Care Center. LPA was met by Administrative Assistant Jennifer Pineda, and was later joined by the Administrator Sabrina Tucker. The facility is licensed to serve 40 Non-Ambulatory residents age's 60 and above, and has two floors.

During today's visit, LPA toured rooms on the first and second floor. Room number: 230, 228,221,107,121,125,128 were checked. LPA observed resident rooms to be clean, and free of odor. The Bedrooms have required furnishings including required bedding, adequete lightening, and functioning bathrooms, with skid mats, and grab bars in place. Water Basins were functioning, and free of mold and debris. There is one activity room, kitchen, medication room, dining room, and patio. The patio was enclosed, and one water fountain was observed. All walkways were clear and free of obstructions and debris. The facility has central air and heating accommodations.

LPA observed the kitchen located on the first floor, is used to keep meals warm before serving. The commercial kitchen that food is prepared at is located at the Skilled nursing facility on campus.

LPA reviewed Staff files, Resident files, and Medication Records, files contained required documentation, and
were up to date.

LPA Observed all staff to be wearing masks, and a 30 day supply of PPE was readily available.

An Exit interview was conducted, and no citations were issued during this visit.
A copy of this report was given.
SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade JordanTELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2021
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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