197603736-5-16-2023-28-AS-ALOZ-CRVUJW-20230516153813

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197603736
Report Date: 05/16/2023
Date Signed: 05/16/2023 03:38:33 PM

Document Has Been Signed on 05/16/2023 03:38 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
GREATER LA AC/SC, 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:	05/16/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:39 AM
MET WITH:	Barbara Boiston, House Manager		TIME COMPLETED:	03:49 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) Alberto Lopez conducted an unannounced annual visit using the Care Evaluation Tool. LPA met with Staff Arlene Fabia and explained the reason for the visit. House Manager Barbara Boiston joined LPA later and assisted with the visit. Physical Plant was toured. The facility is licensed for six (6) residents over the age of 60. Facility has Hospice waiver for 6 residents The facility is a single-story building. LPAs toured the home and inspected nine (4) resident bedrooms rooms 2.5 bathrooms, kitchen, dining room, living room, office, storage room, and laundry room, and attached garage. Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting residents and medications. Disposals of trash are done immediately. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and but Infection control plan was not at facility. Physical Plant & Environment Safety: . There are 4 resident bedrooms, 2 shared rooms 2.5 bathrooms, 2 with showers, living room/activity room, dining room, kitchen, laundry room. Facility has operable smoke and carbon monoxide combo detectors located in hallway and was tested. Knives, cleaning solutions, and disinfectants are locked in the cabinets. No firearms or weapons are stored at the facility. LPA measured the hot water temperature in the kitchen sink. The hot water temperature in measured 136.7 degrees F which is not within the required range of 105-120 degrees F. New Construction was done without submitting permit to department. Operational Requirements The licensee provides care and supervision as required. Plan of operation was not at facility for inspection. Staffing: There appears to be sufficient staffing at the facility. The administrator’s certificate expires 09/06/2024 Staff employed are all over the age of 18. Planned Activities: Facility staff encourage residents to participate in activities. (Continued on 809C)

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

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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Document Has Been Signed on 05/16/2023 03:38 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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: 05/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.605

Other Provisions

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above . Facility did not have proof of liability insurance at facility which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/23/2023
	Plan of Correction
1 2 3 4	Licensee will send proof of current liability insurance to LPA by POC date.

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). 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 in [count] out of [total count] [(objects) (persons)] [identifiers]. Water temperature measured 137.9 which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/17/2023
	Plan of Correction
1 2 3 4	Licensee will adjust water and send proof to LPA by POC date.

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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/16/2023 03:38 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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: 05/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87208(a)

Plan of Operation

(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/23/2023
	Plan of Correction
1 2 3 4	Licensee will send plan of operation to LPA by POC date.

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. 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. The two perimeter gates/doors at each side of the home are in disrepair and one does not open. which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/06/2023
	Plan of Correction
1 2 3 4	Licensee will repair both gates/doors at each side of the home and make sure they open from the inside and send proof to LPA by POC date.

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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/16/2023 03:38 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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: 05/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87305(a)

Alterations to Existing Buildings or New Facilities

Prior to construction or alterations, all facilities shall obtain a building permit. 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. Facility completed new construction in the back of the facility and did not provide department with permit prior to construction which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/23/2023
	Plan of Correction
1 2 3 4	Licensee will provide department with copy of building permit for completed construction.

Type B

Section Cited

CCR

87465(d)

Incidental Medical and Dental Care Services

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, and record review, the licensee did not comply with the section cited above. Some medications were missing labels and PRN authorization letters which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/30/2023
	Plan of Correction
1 2 3 4	Licensee will obtain PRN authorization letters and place labels on medications and send proof to LPA by POC date.

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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ST. JAMES HOME FOR THE ELDERLY	FACILITY NUMBER: 197603736
	VISIT DATE: 05/16/2023

NARRATIVE

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Resident Rights/Information: Resident rights are posted at facility and staff are familiar with resident rights.
Personnel Records-Training: Staff files are maintained at the facility. All staff have current CPR first aid training. Facility has documentation on file that verify CPR for all staff.
Residents Records-Information: Resident files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, pre-admission assessment and other required documentation.
Food Service: There are sufficient food supplies of 2-day perishable and a week (7 days) of non-perishable items. The food is properly stored in the refrigerator to avoid cross contamination.
Incidental Medical & Dental: The medications are centrally stored and in their original containers. During the visit today, LPA reviewed 6 client’s medication and medication is administered following physician’s orders. PRN letters were not on file and labels for PRN
Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Last emergency drill 02/24/2023
Residents with Special Health Needs: Facility accepts and retains residents with special health needs.

During the visit today, LPA observed deficiencies at time of visit. See 809D Technical advisories were provided House Manager Barbara Boiston

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

LIC809 (FAS) - (06/04)

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