197606283-2-2-2023-28-AS-RORN-CPBPPT-20230223103004

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606283
Report Date: 02/02/2023
Date Signed: 02/02/2023 12:17:16 PM

Unsubstantiated

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
01/26/2023 and conducted by Evaluator Glenn Trueman

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230126101520

FACILITY NAME:	ST. JUDES HOMES FOR THE ELDERLY II		FACILITY NUMBER:	197606283
ADMINISTRATOR:	MARY ANN MCGEE		FACILITY TYPE:	740
ADDRESS:	4944 BUFFINGTON ROAD		TELEPHONE:	(909) 936-5424
CITY:	EL MONTE	STATE: CA	ZIP CODE:	91732
CAPACITY:	6	CENSUS: 6	DATE:	02/02/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Manager Virgie Vicente		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Facility does not have adequate food supply.

INVESTIGATION FINDINGS:

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Licensing Program Analyst's ( LPA's) Glenn Trueman and Erik Zaragoza made an unannounced visit to the facility and was greeted by Manager Virgie Vicente and explained the reason for the visit.
The purpose of the visit is to investigate the above allegation..
At 9:45 A.M. LPA's along with Caregiver toured the facility which included 3 resident bedrooms, 2 resident bathrooms, living room, dining room and kitchen and food supply.
Resident and Staff Roster submitted.
Staff S1 and S 2 interviewed from 10:00 A.M. to 10:30 A.M.
Interviews were conducted with Resident (R1-R3) from 10:30 A.M. to 11:00 A.M.
In regards to the allegation Facility does not have adequate food supply, based on interviews and observation during tour of facility there was a sufficient supply of 2 days of perishable foods which included chicken, beef and pork. 7 day supply of non-perishables were sufficient with beans, and soup.
There was a sufficient supply of milk, vegetables and fruits.
All residents interviewed stated that they receive all 3 meals and a snack and there is an adequate supply

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023

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 4

Control Number 28-AS-20230126101520

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. JUDES HOMES FOR THE ELDERLY II	FACILITY NUMBER: 197606283
	VISIT DATE: 02/02/2023

NARRATIVE

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of food.
Residents stated they can get a substitute if they wanted and they have never missed a meal.
Staff interviewed stated that residents are always prepared 3 meals and they have never missed a meal.
Staff stated that a list is compiled by the manager and given to the Administrator on Tuesday and the Administrator provides food for the facility every Wednesday.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
01/26/2023 and conducted by Evaluator Glenn Trueman

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230126101520

FACILITY NAME:	ST. JUDES HOMES FOR THE ELDERLY II		FACILITY NUMBER:	197606283
ADMINISTRATOR:	MARY ANN MCGEE		FACILITY TYPE:	740
ADDRESS:	4944 BUFFINGTON ROAD		TELEPHONE:	(909) 936-5424
CITY:	EL MONTE	STATE: CA	ZIP CODE:	91732
CAPACITY:	6	CENSUS: 6	DATE:	02/02/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Manager Virgie Vicente		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Uncleared staff.

INVESTIGATION FINDINGS:

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In regards to the allegation Uncleared staff, based on interviews conducted and information gathered Staff S 1 confirmed that she does not have fingerprint clearance and had been hired in October 2022.
Manager interviewed stated that S1 was hired in October 2022 and has worked 2 to 3 days a week and does not have fingerprint clearance, but is scheduled for an appointment on 02/03/2022.
LPA verified with the Regional Office telephonically that S 1 does not have fingerprint clearance.
Facility Personnel Report Summary did not list S1 on the report as an individual with clearance.

Based on LPA's observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22) cited on the attached 9099 D.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023

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 4

Control Number 28-AS-20230126101520

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. JUDES HOMES FOR THE ELDERLY II	FACILITY NUMBER: 197606283
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/02/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/03/2023 Section Cited CCR 87355(e)(1)	1 2 3 4 5 6 7	Criminal Record Clearance All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department	1 2 3 4 5 6 7	The licensee will remove the individual in question from the facility and initiate a criminal background clearance. The documents will be provided to the LPA by the POC due date.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Licensee failed to obtain a California Clearance with Staff S1 confirming that she did not have a fingerprint clearance which posed an Immediate Health and Safety Risk to Residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 4