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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607902
Report Date: 12/04/2022
Date Signed: 12/04/2022 03:15:52 PM


Document Has Been Signed on 12/04/2022 03:15 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:ST. MICHAELS HOME FOR THE ELDERLYFACILITY NUMBER:
197607902
ADMINISTRATOR:JAMES MCGEEFACILITY TYPE:
740
ADDRESS:1506 S. CANDISH AVENUETELEPHONE:
(951) 532-4644
CITY:GLENDORASTATE: CAZIP CODE:
91740
CAPACITY:6CENSUS: DATE:
12/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Barbara Boiston - House ManagerTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Mora conducted an unannounced annual visit at the facility with focus on the infection control domain, medication and food review. LPA Mora met with Barbara Boiston (House Manager) and explained the reason for the visit. The facility is licensed to serve 6 non-ambulatory residents ages 60 and over, and may retain up to one hospice resident. The facility is not operating within the scope of its license due to having 1 bedridden resident and 3 hospice residents in total.

The facility is located in a residential area. A tour of the single-story facility included: 2 living rooms, dining room, kitchen, 4 resident bedrooms, 3 resident bathrooms, attached garage, pool, front yard and backyard. LPA and Barbara toured the facility and the following was observed: sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen and garage refrigerator. Auditory devices were seen on all exit doors which are required for dementia residents and were operating at the time of the visit. The water temperature was tested in the residents’ bathrooms and measured at 111.3, 109.7 and 111.5 degrees F which is within the required 105 - 120 degrees F. The bathrooms are clean and have the required grab bars in the shower and near the toilet for non-ambulatory residents. The shower has non-skid materials. Resident bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have enough closet space. Resident beds have the required linen and the linen is in good condition. There is extra clean linen and towels in a hallway closet. Smoke detectors were observed in each room and throughout the facility and are properly operating. Carbon monoxide was observed in the hallway and is properly operating. Fire extinguisher was observed in the kitchen which is fully charged. Kitchen appliances are clean and were operating at the time of the visit. Knives are kept locked in a kitchen cabinet. Cleaning chemicals are kept locked under the kitchen sink. First Aid kit was fully stocked with current manual and it is kept locked in the medication cabinet. The front and backyard are well maintained. There is a shaded seating area for the residents located in the backyard. The pool has a secured gate around it. Passageways and exits are free of obstruction. Residents medication are centrally stored in a locked kitchen cabinet. Residents files are centrally stored in the medication cabinet. Staff files are kept off-site. (CONTINUED TO LIC 809C)
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis MoraTELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:
DATE: 12/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2022
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 6


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. MICHAELS HOME FOR THE ELDERLY
FACILITY NUMBER: 197607902
VISIT DATE: 12/04/2022
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LPA reviewed medication for all 6 of the residents and observed that medications were given as prescribed. LPA reviewed files for all 6 of the residents and observed no deficiencies. Staff files were not available during the visit for review.

Facility is following COVID 19 recommendations regarding screening visitors, staff, and residents. Signs are posted throughout the facility, and hand-washing signs were observed in bathroom. Sufficient hand soap, hand sanitizer, and paper towels were observed. Supply of 30-day Personal Protective Equipment (PPE) was observed in the garage.

The licensee was granted a waiver under the Authority of Governor Newsom’s Executive Order N-11-22 issued on June 17, 2022, and the licensee agreed to submit the Infection Control Plan by 03/04/2023.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there was no deficiencies observed during the visit. Exit interview held and a copy of the report were provided.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis MoraTELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2022
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 12/04/2022 03:15 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: ST. MICHAELS HOME FOR THE ELDERLY
FACILITY NUMBER: 197607902

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)(2)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 6 residents which poses an immediate health, safety or personal rights risk to persons in care. R1's physician report stated that R1 is considered bedridden.
POC Due Date: 12/05/2022
Plan of Correction
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Licensee is to submit an LIC 200 and facility sketch which clarifies the room with the bedridden resident or will obtain physician's report with non-ambulatory status and submit proof to CCLD by 12/05/2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Luis MoraTELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:
DATE: 12/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2022
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 12/04/2022 03:15 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: ST. MICHAELS HOME FOR THE ELDERLY
FACILITY NUMBER: 197607902

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(f)
Personnel Records
(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. Staff files were not available for LPA to review during the visit.
POC Due Date: 12/12/2022
Plan of Correction
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Licensee will submit copies of the staff files to CCLD by 12/12/2022.
Type B
Section Cited
CCR
87412(g)
Personnel Records
(g) All personnel records shall be maintained at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. Staff files are kept off-site.
POC Due Date: 12/12/2022
Plan of Correction
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Licensee will ensure that staff files are kept at the facility and will submit a statement that they understand this regulation to CCLD by 12/12/2022.

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: Luis MoraTELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:
DATE: 12/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2022
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 12/04/2022 03:15 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: ST. MICHAELS HOME FOR THE ELDERLY
FACILITY NUMBER: 197607902

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87632(a)
87632 Hospice Care Waiver
(a) In order accept or retain terminally ill residents and permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department. To obtain this waiver the licensee shall submit a written request for a waiver to the Department on behalf of any residents who may request retention, and any future residents who may request acceptance, along with the provision of hospice services in the facility. The request shall include, but not be limited to the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. R1, R2 and R3 are all hospice residents and facility is licensed to have 1 hospice resident only.
POC Due Date: 12/12/2022
Plan of Correction
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Licensee will submit a new hospice care waiver request to increase their current hospice waiver to CCLD by 12/12/2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis MoraTELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:
DATE: 12/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2022
LIC809 (FAS) - (06/04)
Page: 6 of 6