197603736-5-24-2024-28-AS-VMAO-D5KS67-20240524133527

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197603736
Report Date: 05/24/2024
Date Signed: 05/24/2024 01:35:38 PM

Document Has Been Signed on 05/24/2024 01:35 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
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:	05/24/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Barbara Boiston- House Manager		TIME COMPLETED:	01:45 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) V. Maldonado made an unannounced visit at the facility for the purpose of conducting the required annual inspection, using the Compliance and Regulatory Enforcement (CARE) Tool, to evaluate the facility. LPA Maldonado met with House Manager, Barbara Boiston, and explained the purpose for the visit. During today's visit, LPA Maldonado conducted a tour of the physical plant with Barbara, observed the facility food supplies, reviewed (6) resident medications, (6) resident files, (3) staff files, conducted interviews with (3) staff, and attempted interviews with (6) residents. The facility is a single-story home, operating as a Residential Care Facility for the Elderly (RCFE). It is licensed to serve (6) older adults, ages 60 and over. There is a fire clearance approved for (6) non-ambulatory residents. It has an approved Dementia Care Plan and a Hospice Waiver approved for (6) residents. There are currently (2) residents receiving hospice services. An approved mitigation plan is in place and Infection Control plan has been submitted to the department for review. The facility has an active and current liability insurance policy on file. However, the coverage is insufficient. The general aggregate is currently at $750,000 and each occurrence is at $250,000, which is not in compliance. During the physical plant inspection, LPA observed a new building construction in the back of the property with a new address: 1044 Claraday St. Glendora, CA 91740. House Manager provided LPA a copy of the city permit issued to Licensee on 2/03/23. Per house manager, an application has been submitted to the licensing department for the new property to be licensed as an RCFE. (Report Continued on LIC9099-C...)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024

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
	VISIT DATE: 05/24/2024

NARRATIVE

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LPA observed all resident bedrooms to have the required furniture, sufficient lighting, and closet/storage space. There are (2) full bathrooms and one half bathroom. All restrooms are equipped with required grab bars and non-skid mats for the showers. The hot water was tested and measured at 117*F, which is in compliance. Food supplies was observed and was sufficient as required. Emergency food supplies and water were available. No bodies of water were observed on the premises. Fire extinguishers were observed throughout, with current inspections and were fully charged. All sharps and cleaning supplies/toxins were observed to be locked and inaccessible to residents in care. The last emergency disaster drill was conducted on 4/19/24. Auditory devices were observed at all entrances/exits of the home and were operational. (6) resident files and (3) staff files were reviewed and observed to be complete with all required documentation. (6) resident medications were reviewed and observed to be documented properly and given as prescribed.

Per California Code of Regulations, Title 22, and Health and Safety Codes, deficiencies were observed during today's visit and will be cited on the LIC809-D page.

An exit interview was conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/24/2024 01:35 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
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: 05/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

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 by not maintaining sufficient liability insurance coverage as required, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/31/2024
	Plan of Correction
1 2 3 4	Licensee will obtain sufficient liability insurance coverage, $1,000,000.00/each occurrence and $3,000,000.00/general aggregate as requried by the Health and Safety Code and will submit proof to LPA, via email, by POC due date.

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: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024

LIC809 (FAS) - (06/04)

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