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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606284
Report Date: 04/13/2022
Date Signed: 04/13/2022 03:30:02 PM


Document Has Been Signed on 04/13/2022 03:30 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. JUDES HOMES FOR THE ELDERLY IIIFACILITY NUMBER:
197606284
ADMINISTRATOR:TERRY B. MCGEEFACILITY TYPE:
740
ADDRESS:4942 BUFFINGTON ROADTELEPHONE:
(909) 936-5424
CITY:EL MONTESTATE: CAZIP CODE:
91732
CAPACITY:6CENSUS: 6DATE:
04/13/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:02 PM
MET WITH:Manager Virgie VicenteTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) made an unannounced visit and met with Manager Virgie Vicente to conduct the Annual Inspection.
During the course of the inspection the following deficiency was observed:
87465(a)(4)- Client 1 was not administered PM medications Quetiapine 25mg.,Docusate Sodium 100 mg., and Atorvastatin 20 mg. on 4/12/2022.

Deficiency cited on 809 D.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn TruemanTELEPHONE: (323) 981-1652
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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Document Has Been Signed on 04/13/2022 03:30 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. JUDES HOMES FOR THE ELDERLY III
FACILITY NUMBER: 197606284

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/14/2022
Section Cited

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Incidental Medical and Dental Care
A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self administered medication as needed.

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This requirement was not met as evidenced by:
Based on documentation, review and interview licensee failed to provide assistance with self administered medication with Client # 1 missing evening dose of medication Quetiapine 25mg.,Docusate Sodium 100 mg., and Atorvastatin 20 mg. which posed an Immediate Health and Safety Risk to resident in care.
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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: Glenn TruemanTELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2022
LIC809 (FAS) - (06/04)
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