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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600306
Report Date: 10/26/2024
Date Signed: 10/26/2024 02:39:46 PM

Document Has Been Signed on 10/26/2024 02:39 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ST. JUDES ELDER CAREFACILITY NUMBER:
198600306
ADMINISTRATOR/
DIRECTOR:		MARY ANN MCGEEFACILITY TYPE:
740
ADDRESS:103 BEN AVON COURTTELEPHONE:
(909) 936-5424
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
10/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:42 PM
MET WITH:kurt Santos Care giverTIME VISIT/
INSPECTION COMPLETED:
02:50 PM
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LPA was met by Care giver Kurt Santos and explained the purpose of the visit. Administrator Judy Ragano was notified by phone. The facility is a single-story home, operating as a Residential Care Facility for the Elderly. It is licensed to serve (6) older adults, ages 60 and over. There is a fire clearance approved for (6) non-ambulatory residents. It has an approved Dementia Care Plan and a Hospice Waiver approved for (6) residents.

The facility is a single-story building located in a residential area with four (4) resident bedrooms, two (2) bathrooms, kitchen, dining room, living room, front yard, backyard, and attached garage.

LPA toured the facility and observed the following: Each client bedroom has the required furniture and bedding. There is extra clean linen and towels in a hallway closet. Smoke detectors/carbon monoxide detectors were observed in each room and throughout the facility and are properly operating. There is 1 carbon monoxide in the hallway and is properly operating. The facility has three (3) fully charged fire extinguishers which is kept in the kitchen, hallway, and garage. Cleaning supplies and toxic substances were observed to be inaccessible to clients in cabinet. Freezers are maintained at a temperature of 0-degree F and the refrigerators at a maximum of 40 degrees F. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. Sharps are locked and placed in cabinet in kitchen. There are no firearms or weapons stored at the facility. There are (2) full bathrooms in the home- both equipped with required grab bars and non-skid mats for the shower. The hot water temperature in the bathrooms were measured between required range of 105-120 degrees F. The facility does not have a swimming pool or bodies of water on the premises There is a shaded seating area for the residents located in the backyard. Passageways and exits are free of obstruction. The garage is clean and has extra supplies and food.

SEE LIC809C

Tony VasalloTELEPHONE: (323) 981-3977
Christian GutierrezTELEPHONE: 323-981-3984
DATE: 10/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2024
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ST. JUDES ELDER CARE
FACILITY NUMBER: 198600306
VISIT DATE: 10/26/2024
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Five (5) Staff files were reviewed and included Criminal clearance record, CPR/training, and health screening with TB. Six (6) Client files were reviewed and included physicians report, TB clearance. Fire/earthquake drill was last conducted in October of 2024. Infectious control plan was reviewed. The medications are centrally stored and locked in a cabinet in dining room. The facility uses the Medication Administration Record (MAR) log to document medications given. LPA reviewed medications for all clients, and they are being administered as prescribed by the physician.

No deficiencies were observed or cited during today's inspection exit interview conducted and a copy of the report was provided.



SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Christian GutierrezTELEPHONE: 323-981-3984
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2024
LIC809 (FAS) - (06/04)
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