198601667-6-1-2023-28-AS-LMOA-CSE2BM-20230601171522

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601667
Report Date: 06/01/2023
Date Signed: 06/01/2023 05:15:35 PM

Document Has Been Signed on 06/01/2023 05:15 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. FRANCIS HOME FOR THE ELDERLY III		FACILITY NUMBER:	198601667
ADMINISTRATOR:	JAMES MCGEE		FACILITY TYPE:	740
ADDRESS:	1654 RUDDOCK ST		TELEPHONE:	(626) 502-1173
CITY:	COVINA	STATE: CA	ZIP CODE:	91724
CAPACITY:	6	CENSUS: 6	DATE:	06/01/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:38 AM
MET WITH:	Barbara Boiston - Administrator		TIME COMPLETED:	05:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Luis Mora conducted an unannounced annual visit using the CARE Tool. LPA met with Jayvee De Jesus (Caregiver) and explained the reason for the visit. The Administrator, Barbara Boiston, arrived shortly after. The facility is licensed to serve 6 non-ambulatory residents age 60 and above of which 1 may be bedridden. Facility has a hospice waiver for 2 residents. The facility is operating within the scope of its license. A tour of the single-story facility included: living room, kitchen, dining area, 4 resident bedrooms, laundry area, 2 resident bathrooms, 1 staff bathroom, and attached garage. LPA and Jayvee De Jesus toured the facility and the following was observed: the front and backyard are well maintained. There is a shaded seating area for the residents located in the backyard. Passageways and exits are free of obstruction. Auditory devices were seen on exit doors which are required for dementia residents and were operating at the time of the visit. The water temperature was tested in all bathrooms and measured at 110.6 degrees F, 108.1 degrees F, and 106.1 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. Showers also have 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. There is a carbon monoxide in the dining area and is properly operating. There is a fire extinguisher located in the kitchen and it is fully charged. Kitchen appliances are clean and were operating at the time of the visit. Sharps are kept locked in a kitchen cabinet and are inaccessible to residents. Cleaning supplies and toxins are kept in laundry area cabinet and are inaccessible to residents. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. First Aid kit was fully stocked with current manual and it is kept in the hallway cabinet. (Continued to LIC 809-C)

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

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 7

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. FRANCIS HOME FOR THE ELDERLY III	FACILITY NUMBER: 198601667
	VISIT DATE: 06/01/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Residents and staff files are centrally stored in a kitchen cabinet. Residents medication are centrally stored in a locked cabinet in the kitchen. Some medications are kept in the refrigerator, but are not kept in a locked container and are accessible to the residents. LPA reviewed medication for all 6 residents and observed that medications were not given as prescribed for 3 out of 6 residents. Also, 4 out of 6 residents have medication that do not have a doctor's order or label on the medication. LPA reviewed all 6 resident files and 5 staff files. There was no doctor's order for half bed rails for 3 residents that had bed rails attached to their bed. There was no physician report for 1 resident. There was no health screenings in 2 staff files. There was no valid First Aid/CPR certification in 3 staff files. The facility did not have the Plan of Operation and Liability Insurance during the visit for review. LPA observed administrator certificate for Barbara Boiston – 6041117740 with an expiration date of 09/06/2024. LPA interviewed 2 residents and 2 staff.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were deficiencies observed during the visit (Refer to LIC 809-D). Exit interview held and a copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

LIC809 (FAS) - (06/04)

Page: 2 of 7

Document Has Been Signed on 06/01/2023 05:15 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. FRANCIS HOME FOR THE ELDERLY III	FACILITY NUMBER: 198601667
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(2)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. There was medication in the refrigerator that were not in a locked container.
	POC Due Date: 06/02/2023
	Plan of Correction
1 2 3 4	Facility is to ensure that Title 22 Section 87465 regulations are met at all times. Additionally, facility will move the medications in the refrigerator to a locked container by 06/02/2023 and conduct an in-service training with all staff. A sign-in sheet with all staff signatures will be submitted to CCLD by 06/08/2023.

Type A

Section Cited

CCR

87465(c)(2)

Incidental Medical and Dental Care Services

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation interview and record review, the licensee did not comply with the section cited above in 3 out of 6 residents which poses an immediate health, safety or personal rights risk to persons in care. Resident 2 (R2), Resident 3 (R3) and Resident 5 (R5) did not received their medication as prescribed.
	POC Due Date: 06/02/2023
	Plan of Correction
1 2 3 4	Facility is to ensure that Title 22 Section 87465 regulations are met at all times. Additionally, facility will conduct an in-service training with all staff. A sign-in sheet with all staff signatures will be submitted to CCLD by 06/08/2023.

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 Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

LIC809 (FAS) - (06/04)

Page: 3 of 7

Document Has Been Signed on 06/01/2023 05:15 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. FRANCIS HOME FOR THE ELDERLY III	FACILITY NUMBER: 198601667
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(e)

Incidental Medical and Dental Care Services

(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in 4 out of 6 residents which poses an immediate health, safety or personal rights risk to persons in care. Resident 3 (R3) through Resident 6 (R6) had medication with no doctor's order or label on the medication.
	POC Due Date: 06/02/2023
	Plan of Correction
1 2 3 4	Facility is to ensure that Title 22 Section 87465 regulations are met at all times. Additionally, facility will obtain a doctor's order and label for the medication and submit proof to CCLD by 06/08/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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 Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

LIC809 (FAS) - (06/04)

Page: 4 of 7

Document Has Been Signed on 06/01/2023 05:15 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. FRANCIS HOME FOR THE ELDERLY III	FACILITY NUMBER: 198601667
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87208(a)

Plan of Operation

(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and 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. The Plan of Operation was not at the facility for the LPA to review during the annual visit.
	POC Due Date: 06/08/2023
	Plan of Correction
1 2 3 4	Facility is to ensure that Title 22 Section 87208 regulations are met at all times. Additionally, facility will submit a copy of the Plan of Operation to CCLD by 06/08/2023.

Type B

Section Cited

HSC

1569.605

Other Provisions

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care. The liability insurance was not at the facility for the LPA to review during the annual visit.
	POC Due Date: 06/08/2023
	Plan of Correction
1 2 3 4	Facility is to ensure that Health and Safety Code 1569.605 is met at all times. Additionally, facility will submit a copy of the liability insurance to CCLD by 06/08/2023.

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 Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

LIC809 (FAS) - (06/04)

Page: 5 of 7

Document Has Been Signed on 06/01/2023 05:15 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. FRANCIS HOME FOR THE ELDERLY III	FACILITY NUMBER: 198601667
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)(11)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 2 out of 5 staff which poses/posed a potential health, safety or personal rights risk to persons in care. Staff 1 (S1) and Staff 2 (S2) did not have a health screening in their file because they have not completed one.
	POC Due Date: 06/08/2023
	Plan of Correction
1 2 3 4	Facility is to ensure that Title 22 Section 87412 regulations are met at all times. Additionally, facility will submit a copy of the staff health screenings to CCLD by 06/08/2023.

Type B

Section Cited

CCR

87411(c)(1)

Personnel Requirements - General

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 3 out of 5 staff which poses/posed a potential health, safety or personal rights risk to persons in care. Staff 1 (S1) through Staff 3 (S3) did not have a valid First Aid/CPR certification in their file.
	POC Due Date: 06/08/2023
	Plan of Correction
1 2 3 4	Facility is to ensure that Title 22 Section 87411 regulations are met at all times. Additionally, facility will submit a valid copy of the staff First Aid/CPR certification to CCLD by 06/08/2023.

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 Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

LIC809 (FAS) - (06/04)

Page: 6 of 7

Document Has Been Signed on 06/01/2023 05:15 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. FRANCIS HOME FOR THE ELDERLY III	FACILITY NUMBER: 198601667
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(a)

Medical Assessment

(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, 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. Resident 6 (R6) did not have a physician report in their file.
	POC Due Date: 06/08/2023
	Plan of Correction
1 2 3 4	Facility is to ensure that Title 22 Section 87458 regulations are met at all times. Additionally, facility will submit a copy of the resident's physician report to CCLD by 06/08/2023.

Type B

Section Cited

CCR

87608(a)(3)

Postural Supports

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 3 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care. Resident 1 (R1), Resident 2 (R2) and Resident 6 (R6) did not have a doctor's order for the half bed rails they had on their beds.
	POC Due Date: 06/08/2023
	Plan of Correction
1 2 3 4	Facility is to ensure that Title 22 Section 87608 regulations are met at all times. Additionally, facility will submit a copy of the doctor's order for the half bed rails to CCLD by 06/08/2023.

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 Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

LIC809 (FAS) - (06/04)

Page: 7 of 7