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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197603736
Report Date: 09/24/2021
Date Signed: 09/24/2021 11:13:13 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
09/10/2021 and conducted by Evaluator Tony Vasallo
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210910115714
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: 4DATE:
09/24/2021
UNANNOUNCEDTIME BEGAN:
08:23 AM
MET WITH:Barbara Boiston, house managerTIME COMPLETED:
11:25 AM
ALLEGATION(S):
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Residents are not being fed accordingly.
Staff hit a resident while in care.
Staff pushed a resident while in care.
Staff mishandle a resident's personal belongings.
Staff do not ensure the residents consume the appropriate amount of liquids while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vasallo conducted a subsequent complaint visit to investigate the allegations listed above. LPA met with house manager, Barbara Boiston and explained the reason for the visit. The initial complaint visit was conducted on 9/15/21.

The investigation consisted of the following: Interviews were conducted with all 5 residents and 3 staff. Resident files were reviewed and facility was toured including the kitchen, bedrooms, bathrooms and common areas.

The investigation revealed the following: Allegation: Residents are not being fed accordingly. The kitchen and food supply were inspected. The refrigerator had chicken, vegetables, fruit, yogurt, orange juice, milk, eggs, and condiments. Freezer had red meats and fish. The pantry had cookies, crackers, cans of beans, tuna, peas, green beans, and corn. There were bags of rice and beans. On 9/15/21, residents were observed eating breakfast burritos with bacon and eggs, orange juice, coffee, and water. Four out of the five residents interviewed did not have any issues the food. Staff interviewed stated they follow the menu posted in the facility and they have not received any complaints. 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: 09/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021
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-20210910115714
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: 09/24/2021
NARRATIVE
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On 9/24/21, a subsequent visit was made and residents were observed eating pancakes with strawberries and bananas on top, bacon, coffee, orange juice and water. Based on the information obtained, the allegation is unsubstantiated.

Allegation: Staff hit a resident while in care. It's alleged Resident #1 (R1) hit Staff #1 (S1) while in R1's bedroom. Allegedly S1 hit R1 back. Resident #2 (R2) was the alleged witness to the incident and later recanted and indicated R1 hit S1, but S1 did not hit R1. R2's family was interviewed and confirmed R2 recanted the fact that S1 hit R1. R1 was interviewed, but due to cognitive issues could not provide any information about the alleged incident. S1 was interviewed and he/she denied they hit R1. There were no other witnesses to the incident and there are no cameras located where the alleged incident occurred. R1 did not appear to suffer any injuries as a result of the alleged incident. Based on the information obtained, the allegation is unsubstantiated.

Allegation: Staff pushed a resident while in care. This incident also allegedly occurred while R1 and S1 were in the bedroom as stated above. Allegedly R1 hit and pushed S1 and in return S1 hit and pushed R1. As mentioned above, there was no evidence the incident occurred. Based on the information obtained, the allegation is unsubstantiated.

Allegation: Staff mishandle a resident's personal belongings. There were no details about what personal belongings were mishandled. Residents and resident family member interviewed did not corroborate the allegation. Staff interviewed did not have any information and indicated there were no issues with personal belongings. Based on the information obtained, the allegation is unsubstantiated.

Allegation: Staff do not ensure the residents consume the appropriate amount of liquids while in care. Residents interviewed did not corroborate the allegation. Residents report having water throughout the day. Residents were observed drinking water, coffee, and orange juice during meals. Some residents had multiple bottles of water in their rooms. Staff interviewed also did not corroborate the allegation. Based on the information obtained, the allegation is unsubstantiated.

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: 09/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021
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
09/10/2021 and conducted by Evaluator Tony Vasallo
COMPLAINT CONTROL NUMBER: 28-AS-20210910115714

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: 4DATE:
09/24/2021
UNANNOUNCEDTIME BEGAN:
08:23 AM
MET WITH:Barbara Boiston, house managerTIME COMPLETED:
11:25 AM
ALLEGATION(S):
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Staff do not have planned activities for residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vasallo conducted a subsequent complaint visit to investigate the allegations listed above. LPA met with house manager, Barbara Boiston and explained the reason for the visit. The initial complaint visit was conducted on 9/15/21.

The investigation consisted of the following: Interviews were conducted with all 5 residents and 3 staff. Resident files were reviewed and facility was toured including the kitchen, bedrooms, bathrooms and common areas.

The investigation revealed the following: Residents interviewed indicated there are no activities in the home. The only option is to watch television. Staff interviewed indicated residents watch television or go on short walks. Staff did not report any other activities. There were no activity items observed in the facility such as board games, cards, or bingo. There is also no activity calendar posted.

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: 09/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021
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-20210910115714
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: 09/24/2021
NARRATIVE
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Based on observations and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

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

DATE: 09/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20210910115714
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: 09/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/08/2021
Section Cited
CCR
87219(a)(1)
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Planned Activities (a)Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. The activities made available shall include:
(1) Socialization, achieved through activities such as group discussion and conversation, recreation, arts, crafts, music......
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House manager indicated all staff will be trained on planned activities. Facility is also looking into volunteers from local schools. Proof of training will be submitted for review.
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Deficiency was evidenced by the following:
Interviews revealed there are no activities in the home. The only option is to watch television. There were no activity items observed and no activity calendar posted.
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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: 09/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5