197603736-5-14-2021-28-AS-TVAO-C2ZRPF-20210514131152

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197603736
Report Date: 05/14/2021
Date Signed: 05/14/2021 01:12:29 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	ST. JAMES HOME FOR THE ELDERLY		FACILITY NUMBER:	197603736
ADMINISTRATOR:	JENNIFER LYNN MCGEE		FACILITY TYPE:	740
ADDRESS:	1042 CLARADAY STREET		TELEPHONE:	(626) 335-1995
CITY:	GLENDORA	STATE: CA	ZIP CODE:	91740
CAPACITY:	6	CENSUS: 6	DATE:	05/14/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:53 AM
MET WITH:	House Manager, Barb Bioston		TIME COMPLETED:	01:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Vasallo and Margaryan conducted an annual required visit. LPA's met with Barb Boiston and explained the reason for the visit. LPA's used the infection control tool to evaluate the facility. LPA's observed the facility plant, COVID-19 procedures, reviewed residents' medications, observed food supply, and reviewed staff files. All 4 resident bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, and sufficient closet space. All 3 bathrooms were toured. Bathrooms have the required grabs bars and non-skid mat. The hot water was 105 degrees which is within the required 105 - 120 degrees. The hallway bathroom had cleaning supplies such as Comet and bleach under the sink that was not locked or inaccessible to residents. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are cleaning and working properly. The common areas such as living room and dining room are clean and have the required furniture. The back yard has a shaded area and sitting area. This area is currently being used for visitation. LPA's reviewed 2 resident files to confirm emergency contact is updated and residents have health screenings and or vaccinations. LPA's also reviewed staff files to confirm health screenings and fingerprint clearances. LPA's reviewed 2 residents' medications. Medications are documented and stored properly. The deficiency cited is documented on the attached 809D. A copy of the report and appeal rights will be provided to house manager via email.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ST. JAMES HOME FOR THE ELDERLY	FACILITY NUMBER: 197603736
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/14/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(2)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPA's observed hallway bathroom had cleaning supplies such as Comet and bleach under the sink that was not locked or inaccessible to residents. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/14/2021
	Plan of Correction
1 2 3 4	During the visit, caregiver immediately removed the items to the laundry room. House manager also indicated that maintenance will be visiting today to install a latch or lock to the bathroom cabinet.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2021

LIC809 (FAS) - (06/04)

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