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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191800633
Report Date: 01/27/2025
Date Signed: 01/27/2025 02:57:23 PM

Document Has Been Signed on 01/27/2025 02:57 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/
DIRECTOR:		SABRINA TUCKERFACILITY TYPE:
740
ADDRESS:2468 SO. ST. ANDREWS PLACETELEPHONE:
(323) 731-0641
CITY:LOS ANGELESSTATE: CAZIP CODE:
90018
CAPACITY: 40; 40CENSUS: 31DATE:
01/27/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:OPHELIA CRUZ - PATIENT CARE COORDINATOR TIME VISIT/
INSPECTION COMPLETED:
02:54 PM
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On 01/27/2025, Licensing Program Analyst (LPA) Troy Watson conducted an unannounced subsequent annual visit using the CARE Inspection Tool. LPA met with the Patient Care Coordinator Ophelia Cruz. LPA Watson toured the physical plant with the supervisor. There were no bodies of water or obstructions on the premises. A total of(8) rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. LPA inspected the smoke/carbon monoxide detectors combo and found that they were recently inspected and in operable condition. The water temperature properly measured between: 111.8 °F and 114°F, between the bathrooms and in the kitchen.

Evaluation Report Continues LIC 809-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2025
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: 01/27/2025
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LPA Troy Watson observed the facility to be clean, sanitary, and appropriately furnished at the time of the visit. Storage areas for personal hygiene were observed. Sharps objects in the facility kitchen and cleaning agents were locked and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available at the property. All fire extinguishers were charged and were operable.The personnel files, resident files and MARs were reviewed. The first AID kits was checked and contained the correct manual, tweezers, scissors, tape, and gauze. LPA observed the facility's infection control practices. All required postings were displayed and present at the facility.

An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Ophelia Cruz.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025
LIC809 (FAS) - (06/04)
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