198320433-4-22-2024-11-AS-AINZ-D4KUEF-20240422153103

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320433
Report Date: 04/22/2024
Date Signed: 04/22/2024 03:31:09 PM

Document Has Been Signed on 04/22/2024 03:31 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	JEANNE JUGAN RESIDENCE		FACILITY NUMBER:	198320433
ADMINISTRATOR:	AGUILOS, ROBERT		FACILITY TYPE:	740
ADDRESS:	2100 SOUTH WESTERN AVENUE		TELEPHONE:	(310) 548-0625
CITY:	SAN PEDRO	STATE: CA	ZIP CODE:	90732
CAPACITY:	86	CENSUS: 27	DATE:	04/22/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:44 AM
MET WITH:	Grace Mercado/Licensee		TIME COMPLETED:	03:30 PM

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On 4/22/24 LPM Eva Alvarez and LPA Alfonso Iniguez conducted an unannounced pre-licensing change of ownership visit at this facility. LPM and LPA were met by Robert Aguilos (Administrator) and Grace Mercado (Licensee). The purpose of today’s visit was explained.

There are currently (27) residents residing in the facility. The facility is a (3) floor building and consists of (96) bedrooms, (75) bathrooms, commercial kitchen, large dining room, auditorium, storage areas, nursing stations, activities rooms, exercise room, recreation room, medical supply room, craft room, gift shop, conference rooms, shaded patio area, side courtyard, patio, and laundry rooms. The facility has applied for a total of (86) residents of which (77) non-ambulatory and (9) bedridden. Bedridden rooms are: 201, 202, 203, 204, 205, 206, 207, 208 and 209.

A tour of the entire facility was conducted: basement floor, first floor, second floor, third floor, kitchen, common areas, outside of facility, medication room, records room, generator bathrooms, activity program, weekly menus.

The following was observed during this visit:

MEDICATIONS

There is a locked centralized storage area for Resident medications.

PHYSICAL PLANT

Facility is clean, sanitary, and in good repair. Protective devices are in place. Indoor and outdoor passageways, stairways, open porches, and other areas of potential hazard are free of obstructions. All window screens are clean and in good repair. Facility temperature is between 68°F. degrees and 73°F. degrees. Open porches, and areas of potential hazard are well-lit. Smoke alarms operate properly. Carbon monoxide detectors operate properly.

Report continues LIC 809C.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2024

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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: JEANNE JUGAN RESIDENCE	FACILITY NUMBER: 198320433
	VISIT DATE: 04/22/2024

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BEDROOMS

There is a bed for each client with a mattress, mattress pad, bedsprings, and pillow(s) which are clean and in good repair.

Mattresses and pillows are flame-retardant. There is dresser and closet space for each client that includes at least two (2) drawers or eight (8) cubic feet of dresser space per client. There is a chair and lamp for each client and at least one (1) nightstand per two (2) clients.

BATHROOMS

There is at least one (2) toilet and washbasin per six (6) clients, family, and personnel. There is at least one (2) shower or bathtub per ten (10) clients, family, and personnel. Hot water temperature is 113° Fahrenheit. Bathroom is located near client bedrooms. There are night-lights in the hallways outside non-private bathrooms.

SUPPLIES

There are client personal hygiene supplies to include soap, toothpaste, toilet paper, and comb. There is a sufficient supply of clean linens to permit weekly changing or more of client top sheets, bottom sheets, bedspreads, blankets, pillowcases, mattress covers, bath towels, hand towels, and washcloths.

FOOD SERVICE

Dining room is near kitchen. Refrigerator(s) and freezer(s) are clean and large enough for the storage of at least two (2) days of perishable foods. Freezer is 0° Fahrenheit. Refrigerator is a maximum of 45° Fahrenheit. A seven (7) day supply of non-perishable food is present. There are enough tableware, tables, dishes, and utensils. There is enough equipment for the storage, preparation, and service of food. All equipment, dishes, and utensils are clean and well maintained. All kitchen, food storage, and preparation areas are clean.

Report continues LIC 809C.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2024

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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: JEANNE JUGAN RESIDENCE	FACILITY NUMBER: 198320433
	VISIT DATE: 04/22/2024

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RECORDS

There is confidential storage of personnel records at the facility. There is confidential storage of client records at the facility.

ADMINISTRATION

The emergency exiting plan and emergency phone numbers are posted. Client Personal Rights are posted. Posting both sides of the Personal Rights form LIC 613 meets this requirement. Facility Visiting Policy is posted. Licensing Complaint Poster is posted. There is space available for resident council meetings and resident council postings.

ACTIVITIES

There is an outdoor activity space with a shaded area and furnished for outdoor use. There is at least one common room available to clients for visitors.

MISCELLANEOUS

There are first-aid supplies to include sterile first-aid dressings, bandages, adhesive tapes, scissors, tweezers, thermometer, antiseptic solution, and a current first-aid manual. There is space and equipment for laundry. There is a space for clean linen storage and a separate space for soiled linen. There is an operating telephone available to clients. Emergency lighting and supplies to include flashlights with batteries.

A review of (2) residents' service files (R1-R2) and (4) staff personnel files (S1-S4) were maintained in order. LPA reviewed (2) Medication Administration Records (MARs) and no discrepancies were found.

During this pre-licensing inspection, LPAs did not find corrections were needed. LPA Iniguez conducted the Component III Orientation with the Licensee and copy of this report was provided. A copy of the facility evaluation report will be available to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with their assigned CAU Analyst.

Exit interview conducted with Grace Mercado /Licensee

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2024

LIC809 (FAS) - (06/04)

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