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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197603736
Report Date: 07/02/2021
Date Signed: 07/02/2021 11:33:17 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/24/2021 and conducted by Evaluator Tony Vasallo
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210624095307
FACILITY NAME:ST. JAMES HOME FOR THE ELDERLYFACILITY NUMBER:
197603736
ADMINISTRATOR:JENNIFER LYNN MCGEEFACILITY TYPE:
740
ADDRESS:1042 CLARADAY STREETTELEPHONE:
(626) 335-1995
CITY:GLENDORASTATE: CAZIP CODE:
91740
CAPACITY:6CENSUS: 5DATE:
07/02/2021
UNANNOUNCEDTIME BEGAN:
08:11 AM
MET WITH:Barbara Boiston, House ManagerTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Resident was provided another residents medication.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vasallo conducted a complaint visit to investigate the allegations listed above. LPA met with Barbara Boiston, house manager and explained the reason for the visit.

The investigation consisted of the following: LPA observed meals being served. Medications were reviewed at 8:29 am. Facility was toured at 9:00 am. Residents were interviewed starting at 8:58 am. Staff interviews began at 9:14 am.

The investigation revealed the following: It's alleged a resident was given another resident's pain medication. House manager confirmed that on or around 6/20/21, Staff #1 (S1) called house manager and said Resident #1 (R1) was given Resident #2's (R2) over the counter pain medication because R1 was complaining of pain. R1 was a new resident at the time and did not have pain medication at the facility yet. House manager gave S1 a warning not to do that again and explained why it should not be done.
Continued on 9099C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 28-AS-20210624095307
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 07/02/2021
NARRATIVE
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Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the allegation is found to be substantiated. The deficiency is being cited on the attached LIC 9099D.

Exit interview held. A copy of the report and appeal rights were provided to house manager.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/24/2021 and conducted by Evaluator Tony Vasallo
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210624095307

FACILITY NAME:ST. JAMES HOME FOR THE ELDERLYFACILITY NUMBER:
197603736
ADMINISTRATOR:JENNIFER LYNN MCGEEFACILITY TYPE:
740
ADDRESS:1042 CLARADAY STREETTELEPHONE:
(626) 335-1995
CITY:GLENDORASTATE: CAZIP CODE:
91740
CAPACITY:6CENSUS: 5DATE:
07/02/2021
UNANNOUNCEDTIME BEGAN:
08:11 AM
MET WITH:Barbara Boiston, House ManagerTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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3
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9
Residents are not being provided adequate fluids.
Staff is rough with residents.
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA) Vasallo conducted a complaint visit to investigate the allegations listed above. LPA met with Barbara Boiston, house manager and explained the reason for the visit.

The investigation consisted of the following: LPA observed meals being served. Medications were reviewed at 8:29 am. Facility was toured at 9:00 am. Residents were interviewed starting at 8:58 am. 3 out of the 5 residents did not have cognitive impairment and were able to answer questions. Staff interviews began at 9:14 am.

The investigation revealed the following: Allegation: Residents are not being provided adequate fluids. Staff interviewed deny the allegation and stated they always assist residents with water. Residents interviewed did not corroborate the allegation. Residents were observed with water cups/mugs. Based on information obtained, the allegation is unsubstantiated.
Continued on 9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20210624095307
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 07/02/2021
NARRATIVE
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Allegation: Staff is rough with residents. It's alleged staff rush in the morning and are rough with residents. Staff interviewed deny the allegation. Residents interviewed did not corroborate the allegation. Residents deny they have been injured or bruised by staff. LPA observed caregivers assisting residents in morning and did not observe caregivers being rough with residents. Staff also did not appear to be rushing.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20210624095307
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/06/2021
Section Cited
CCR
87465(e)
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Incidental Medical and Dental Care
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication.
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House manager agreed to retrain staff on medication and PRN procedures.
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Deficiency was evidenced by the following: Resident #1 (R1) was given Resident #2's (R2) over the counter pain medication because R1 was complaining of pain. R1 was a new resident at the time and did not have pain medication prescribed at the facility yet.
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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 HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5