197606284-5-17-2024-28-AS-KRAZ-D5CNFY-20240517102619

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606284
Report Date: 05/17/2024
Date Signed: 05/17/2024 10:26:49 AM

Document Has Been Signed on 05/17/2024 10:26 AM - 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. JUDES HOMES FOR THE ELDERLY III		FACILITY NUMBER:	197606284
ADMINISTRATOR:	TERRY B. MCGEE		FACILITY TYPE:	740
ADDRESS:	4942 BUFFINGTON ROAD		TELEPHONE:	(909) 936-5424
CITY:	EL MONTE	STATE: CA	ZIP CODE:	91732
CAPACITY:	6	CENSUS: 6	DATE:	05/17/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Caregiver Adela Osoteo		TIME COMPLETED:	10:30 AM

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*LPA Ramirez conducted physical inspection and report on 05/04/24. LPA Ramirez returned to correct report onto correct facility profile. No changes to findings*

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 05/04/2024. LPA was met by Caregiver Adela Osoteo and explained the purpose of the visit. Facility is licensed to clients over 60 years old, of which six (6) may be non ambulatory. Bedridden fire clearance is approved for three (3) bedrooms. The facility cares for elderly residents with dementia and is allowed to care for six (6) hospice residents. LPA Ramirez observed video surveillance in common areas. LPA requested and obtained a copy of Personnel Report (LIC 500) and Resident Roster (LIC 9020).

LPA OBSERVATIONS: The facility is located on residential street. This facility is located in a duplex. The facility consists of six (6) bedrooms, four (4) bathrooms, one (1) staff room, staff office, kitchen, dining room, living room/den, linen closet, front yard and enclosed backyard.

Front Yard: Clean and well maintained.

Kitchen: LPA observed kitchen to be clean and appliances appeared to be in working order. LPA observed sufficient 2 days of perishables and 7 days of non-perishables. Kitchen sink water temperature was measured at 115.9 degrees F. Sharps were secured and inaccessible to residents.

Dining Room/Living Room: Dining room area was clean, and LPA observed a table with 6 chairs. Living room area contained plenty of seating.

Linen Closet: Contained plenty of linens, towels, and hygiene products.

Resident Rooms 1 - 6: All contained the required furnishings, linens and were observed to be clean. All resident bedrooms are private.

Staff Office: LPA observed PPE supplies. LPA observed emergency food supply and emergency water supply located in cabinet.

See 809- C for continuation.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024

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

FACILITY NAME: ST. JUDES HOMES FOR THE ELDERLY III	FACILITY NUMBER: 197606284
	VISIT DATE: 05/17/2024

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Emergency Drills/Emergency Disaster Plan/First Aid Kit: LPA Ramirez observed Emergency & Disaster Plan (LIC 610E) during inspection. Last two (2) fire drills were conducted on 03/04/24 and 04/07/24. LPA Ramirez observed a First Aid kit in facility medication cabinet.

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher: LPA observed carbon monoxide in hallways and smoke detectors were observed to be operable.

Personnel Records: Personnel records are maintained at facility. LPA Ramirez reviewed staff files for two (2) staff. LPA Ramirez observed First Aid & CPR Certificate, Fingerprint Clearance/ Exemptions, Personnel Record/Job Application, Health Screening, Employee Rights, TB Test, and Initial/Annual Training Verification were observed. LPA Ramirez was unable to gain access to current administrator personnel record. LPA Ramirez observed confirmation of Administrator Antionette Corsentino renewal in process. LPA Ramirez will issue Type B deficiency for not maintaining all personnel records at the facility.

Resident Records: Six (6) resident files were reviewed. Admissions Agreement, Medical Assessment, Consent Forms, Appraisal and Needs and Services plan, I.D and Emergency Information, TB Test, Centrally Stored Medication Record, and Personal Rights Form were observed. LPA Ramirez did not observe medical assessment for R1. LPA Ramirez will issue Type B deficiency.

Liability Insurance & Infection Control Plan: Facility has current liability insurance on file. LPA Ramirez observed updated infection control plan.

Backyard: Well maintained, No large bodies of water were observed.

Two (2) deficiencies are being cited. Exit interview was conducted. A copy of this report, 809-D and appeals rights was provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/17/2024 10:26 AM - 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. JUDES HOMES FOR THE ELDERLY III	FACILITY NUMBER: 197606284
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(g)

(g) All personnel records shall be maintained at the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and observation, not all personnel records were maintained at the facility upon request, the licensee did not comply with the section cited above in 6 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/10/2024
	Plan of Correction
1 2 3 4	Licensee will certify that all personnel records will be maintained at the facility.

Type B

Section Cited

CCR

87458(a)

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, R1 medical assessment was not available during file review, the licensee did not comply with the section cited above in 1 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/17/2024
	Plan of Correction
1 2 3 4	Licensee will obtain medical assessment for R1 and keep on file. Proof of assessment must be faxed to LPA Ramirez by 05/17/2024.

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: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024

LIC809 (FAS) - (06/04)

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