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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191800633
Report Date: 02/01/2024
Date Signed: 02/01/2024 02:15:21 PM


Document Has Been Signed on 02/01/2024 02:15 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245



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: 23DATE:
02/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Arjene AguirreTIME COMPLETED:
02:30 PM
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On 2/1/24 Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced Annual required visit using the CARE tool. LPA was met by Assistant Administrator Arjene Aguirre and the purpose of today’s visit was explained. LPA was granted access into this facility. The facility is licensed to serve 40 non-ambulatory residents ages 60 and above. St. Benidict Menni is the buildings name. Delayed egress approved-dementia special program. Hospice waiver approved for three (3) residents.

There are currently twenty-three (23) residents in placement. The facility is a two-story structure located in a residential neighborhood. It consists of thirty-three (33) resident bedrooms with private bathrooms, dining room, kitchen, living room, shaded area, indoor and outdoor activity area, laundry room and media room.

LPA and Assistant Administrator toured the physical plant inside and out. Bedrooms 225, 230, 216 and 207 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 complying within Title 22 regulations and were clean and operational. The water temperature measured between 105.0 F and 120.0 F. In bathroom 225 water temperature measured at 112.8, in bathroom 230 water temperature measured at 112.3, in bathroom 216 water temperature measured at 113.1, and in bathroom 207 water temperature measured at 113.2. 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 checked and observed to be within Title 22 regulations. Sharps, toxins, cleaning solutions, hazardous items, and medications were secured and inaccessible to residents. Medications were centrally stored and properly locked.

Continued on LIC 809-C

SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Elvira GonzalezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2024
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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: ST JOHN OF GOD RESIDENCE
FACILITY NUMBER: 191800633
VISIT DATE: 02/01/2024
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Smoke detectors and carbon monoxide detectors were operational and working properly. Fire extinguishers were fully charged. LPA observed a stocked First Aid kit along with manual locked and inaccessible to residents. Outside grounds were toured and no bodies of water were observed. Walkways around the facility were clear of hazards.

During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents. There are sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings and all mandated inspection control postings throughout the facility. The facility has an approved CCLD Mitigation Plan.

During this inspection LPA did not observe any deficiencies, therefore no citations were issued at this time.

An exit interview was conducted, and a copy of the Report and Appeal Rights was provided to Assistant Administrator Arjene Aguirre.

SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Elvira GonzalezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024
LIC809 (FAS) - (06/04)
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