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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601713
Report Date: 09/10/2024
Date Signed: 09/10/2024 11:15:55 AM


Document Has Been Signed on 09/10/2024 11:15 AM - 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. PAUL'S HOME FOR THE ELDERLY, INC.FACILITY NUMBER:
198601713
ADMINISTRATOR:PAUL SHAYFACILITY TYPE:
740
ADDRESS:1311 S. GLENCROFT RD.TELEPHONE:
(626) 857-3571
CITY:GLENDORASTATE: CAZIP CODE:
91741
CAPACITY:6CENSUS: 6DATE:
09/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Jade Robles, House ManagerTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) S Vaid made an unannounced visit at the facility for the purpose of conducting the required annual inspection, using the Compliance and Regulatory Enforcement (CARE) Tool, to evaluate the facility. LPA Vaid met with House Manager, Jade Robles and explained the purpose for the visit. Licensee/Administrator, Paul Shay, arrived shortly after to assist with the visit.

During today's visit, LPA Vaid conducted a tour of the physical plant with Jade, observed the facility food supplies, reviewed (6) resident medications, (6) resident files, (3) staff files, and conducted interviews with (2) staff and attempted with (6) residents. 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, of which (1) may be bedridden. It has a hospice waiver approved for (6). Currently, there are (1) resident on hospice.

All resident bedrooms were inspected and had the required furniture, storage space, and lighting. Bathrooms were equipped with a toilet, wash basin, and showers. They were observed to have the required grab bars and non-skid mats. The hot water was tested and measured and is in-compliance. The food supplies were observed and had the required 2-day perishables and 7-day non-perishables, as well as emergency food and water supply available. Fire extinguishers were observed throughout the premises, with current inspections and were fully charged. Walkways and ramps were observed to be free of debris and obstructions/hazards. Auditory devices were observed and operable at all entrances/exits of the facility. Sharps, cleaning supplies, and centrally stored medications were observed stored and inaccessible to residents in care. Laundry equipment was observed in good repair and operational during the visit. Sufficient linens, towels, and personal hygiene supplies were available.

Continued on 809C......
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Sanjay VaidTELEPHONE: 916-215-7924
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2024
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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ST. PAUL'S HOME FOR THE ELDERLY, INC.
FACILITY NUMBER: 198601713
VISIT DATE: 09/10/2024
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The facility has an approved mitigation plan on file and a current infection control plan submitted to the department. Sufficient PPE supplies were observed. Smoke/carbon monoxide detectors were observed in each room. Last fire drill was conducted on July 2024. Staff and resident files were reviewed for required documentation and observed to be complete. Resident's medications were reviewed and observed to be documented properly and given as prescribed.

During today's visit, no deficiencies were observed or cited.

An exit interview conducted with Administrator. A copy of the report was provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Sanjay VaidTELEPHONE: 916-215-7924
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024
LIC809 (FAS) - (06/04)
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