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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601667
Report Date: 05/31/2024
Date Signed: 05/31/2024 03:58:16 PM


Document Has Been Signed on 05/31/2024 03:58 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:ST. FRANCIS HOME FOR THE ELDERLY IIIFACILITY NUMBER:
198601667
ADMINISTRATOR:JAMES MCGEEFACILITY TYPE:
740
ADDRESS:1654 RUDDOCK STTELEPHONE:
(626) 502-1173
CITY:COVINASTATE: CAZIP CODE:
91724
CAPACITY:6CENSUS: 5DATE:
05/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Barbara Boiston, House ManagerTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with House Manager, Barbara Boiston, who assisted with the visit. Facility is licensed to serve six (6) non-ambulatory elderly residents, ages 60 and above, which one (1) may be bedridden.

During the visit, CARE tool was used, a tour of the facility was conducted, food supply/medication were reviewed, staff/residents were interviewed and staff/residents records were reviewed.



The facility is located in a residential neighborhood. The facility consisted of four (4) resident bedrooms, two (2) full bathrooms, one (1) half bathroom, kitchen, living area, dining room, and an indoor/covered outdoor activity area. All the rooms were furnished with appropriate furniture for residents’ comfort. The bathrooms were furnished with grab bars and nonskid surfaces. Common areas were observed for the ability to safely serve the needs of the residents. Hot water temperature was 109.8 degrees Fahrenheit. Adequate linen and personal hygiene supplies were observed. No pools and bodies of water on the premises. Facility maintained a comfortable temperature for residents. Auditory alarm devices to monitor exits were operable. Interior and exterior space available to permit residents to wander freely and safely. Sufficient supply of perishable and nonperishable foods were observed. Knives, tools, sharp items are inaccessible to residents. Smoke detectors and carbon monoxide detectors are operable. Fire extinguishers' last service is 04/04/24 and are fully charged. Medication are centrally stored in a locked cabinet in the kitchen and inaccessible to residents. Resident records are stored in a locked cabinet and inaccessible to residents. Toxic substances are inaccessible to residents.

No deficiencies were observed and cited per California Code of Regulations, Title 22.

An exit interview was conducted. This report was discussed with house manager, Barbara, whose signature on this form confirm receipt of these documents. A copy of LIC 809 report was provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2024
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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