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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603736
Report Date: 04/13/2022
Date Signed: 04/13/2022 11:15:54 AM


Document Has Been Signed on 04/13/2022 11:15 AM - It Cannot Be Edited

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 ELDERLYFACILITY NUMBER:
197603736
ADMINISTRATOR:JENNIFER LYNN MCGEEFACILITY TYPE:
740
ADDRESS:1042 CLARADAY STREETTELEPHONE:
(626) 335-1995
CITY:GLENDORASTATE: CAZIP CODE:
91740
CAPACITY:6CENSUS: 5DATE:
04/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:S-1 and House Manager-Barb BiostonTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced Required-1 year visit focusing on COVID-19 Infection Control Practices. LPA met with S-1 and explained the purpose of today's visit. House Manager arrived at approximately at 10:45AM and assisted with this visit.

This home consists of (4) bedrooms, (3) bathrooms, (2) living rooms, kitchen, dinning area, laundry room, enclosed patio and attached garage.

The following were observed/inspected: .
  • COVID-19 Infection Control Practices (including signs) were observed at the entrance of this facility.
  • PPE supplies and incontinence supplies observed. These items are stored and easily accessible inside the attached garage.
  • Hygiene supplies observed. These items are stored inside the storage cabinet located in the laundry room. Additionally, each Resident has an individual hygiene storage box.
  • Hand Sanitizer observed throughout the facility grounds.
  • Restrooms have hand soap, hand sanitizer and paper towels.
  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed.
  • Medication reviewed for (5) Residents (Residents #1 through Residents #5).
  • Per S-1 Residents are fully vaccinated and have their booster.
  • Per House Manager, staff are fully vaccinated and have their booster.
  • Residents were be socially distanced according to local public health guidelines.
  • Staff responsible for direct care and supervision will continue to wear masks.

Exit interview conducted, a copy of this report and Appeal Rights were provided to House Manager.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2022
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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