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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606284
Report Date: 06/08/2023
Date Signed: 06/08/2023 12:36:59 PM


Document Has Been Signed on 06/08/2023 12:36 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:
06/08/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Virgie Vicente (Caregiver)TIME COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kruz Long conducted a Case Management visit at the facility to issue citations based on observations indicating Staff #2 is present and working at the facility but not listed on the personnel roster. At approximately 11:15 am during a site visit to the facility for other reasons, LPA requested Staff #2's records from Staff #1 but Staff #1 stated the records are not accessible. LPA verified that Staff #2 has criminal record clearance but is not associated to the facility.

Deficiencies cited on the LIC809D page and Immediate Civil Penalties of $500 for Staff #2 documented on LIC421BG.

Exit interview conducted with Virgie Vicente (Caregiver) and a copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz LongTELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 06/08/2023 12:36 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: 06/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/09/2023
Section Cited
CCR
87355(e)(2)

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87355 Criminal Record Clearance
(e) 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: (2) Request a transfer of a criminal record
This requirement is not met as evidenced by:
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Licensee shall ensure Staff #2 is not working for or present at the facility until Staff #2 in associated to the facility and provide proof to the department.
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LPA verified that Staff #2 has criminal record clearance but is not associated to the facility.
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Type B
06/15/2023
Section Cited
CCR87214(g)(1)

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(g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review. (1) The licensee shall be permitted to retain such records in a central administrative location provided that they are readily available to the licensing agency at the facility as specified in Section
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Licensee shall ensure that all personnel records shall be maintained at the facility and shall be available to the licensing agency for review and provide proof to the department by the POC date.
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87412(f).
This requirement is not met as evidenced by: LPA requested Staff #2's records from Staff #1 but Staff #1 stated that the records are not accessible.
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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: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz LongTELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2