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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191800633
Report Date: 02/01/2023
Date Signed: 02/01/2023 04:33:34 PM


Document Has Been Signed on 02/01/2023 04:33 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: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: 24DATE:
02/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:49 PM
MET WITH:Alma MonzonTIME COMPLETED:
04:45 PM
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Licensing Program Manager (LPM) Ulysses Coronel and Licensing Program Analysts (LPAs) Antonine Richard and David Espana conducted an unannounced Annual required visit with a primary focus on infection control measures. The team was met by Alma Monzon,staff and the purpose of today’s visit was explained. The facility is licensed to serve 40 non-ambulatory residents age 60 and above. St. Benidict Menni is the buildings name. Delayed egress approved -dementia special program. Hospice waiver approved for 3 residents.

There are currently 24 Residents in placement. The facility is a two-story structure located in a residential neighborhood. It consists of the following: 30 resident bedrooms with private bathrooms, dining room, kitchen, living room, shaded area, indoor and outdoor activity area, laundry room and activity room.

LPA and staff toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. Bedrooms 208, 215, 223 and 230 were checked. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings were observed. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be in compliance within Title 22 regulations and were clean and operational. The water temperature measured 115.3F.A comfortable temperature is maintained in the facility. LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is a enough perishable and non-perishable food available which is stored properly. Fire extinguishers were charged, smoke detectors and Carbon Monoxide were operable.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff and residents, sanitizing stations ( Located in common areas and restrooms). LPA observed staff were wearing face coverings and required postings throughout the facility. LPAs observed the facility has a 30-day supply of Personal Protective Equipment (PPE).
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Antonine RichardTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


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: ST JOHN OF GOD RESIDENCE
FACILITY NUMBER: 191800633
VISIT DATE: 02/01/2023
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LPAs advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

During today’s visit there were no deficiencies observed.

Exit interview held. A copy of the report was provided to Gerovil Toriano, staff.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Antonine RichardTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3