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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600306
Report Date: 02/08/2022
Date Signed: 02/08/2022 01:58:36 PM

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 ELDER CAREFACILITY NUMBER:
198600306
ADMINISTRATOR:MARY ANN MCGEEFACILITY TYPE:
740
ADDRESS:103 BEN AVON COURTTELEPHONE:
(909) 936-5424
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY:6CENSUS: 6DATE:
02/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator, Judy RaganoTIME COMPLETED:
02:10 PM
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Licensing Program Analyst (LPA) Vasallo conducted an annual required visit. LPA met with Caregiver, Liza Diego and explained the reason for the visit. Administrator was called and arrived a short time later. LPA used the infection control tool to evaluate the facility. LPA observed the physical plant, COVID-19 procedures, reviewed residents' medications, observed food supply, and reviewed staff files. The facility cares for elderly residents and is allowed to have 6 hospice residents. There is currently 1 resident on hospice.

All resident bedrooms were toured. Each bedroom has a bed, linen, dresser, light, and sufficient closet space. The resident bathrooms have the required grabs bars and non-skid mat. The hot water was between 105.9 degrees which is within the required 105 - 120 degrees. Cleaning supplies are inaccessible to residents. The kitchen was inspected. There is sufficient perishable and non-perishable food. There is additional food in the garage. All the appliances are clean and seem to be operating properly. The common areas include the living room and dining room. These areas are clean and have the required furniture. There is a sanitizer station at the entrance of the home. Staff conducted a routine symptom screening of LPA at the time of entrance and have a sign-in policy as required per COVID-19 procedures. The visitation area is the outside patio and living room. There are 2 cameras inside the facility in common areas only.

LPA reviewed 6 resident records to confirm emergency contact is updated and residents have health screenings on file. 2 staff records were reviewed to confirm health screenings, training and fingerprint clearances. LPA reviewed 6 residents' medications. Medications are documented properly and stored in a locked cabinet.

Per California Code of Regulations, Title 22, there were no deficiencies observed during the visit. Exit interview held. A copy of the report was provided to the Administrator.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2022
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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