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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601817
Report Date: 10/26/2022
Date Signed: 10/26/2022 03:09:47 PM


Document Has Been Signed on 10/26/2022 03:09 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:ST JOHN GRANDEFACILITY NUMBER:
198601817
ADMINISTRATOR:SABRINA TUCKERFACILITY TYPE:
740
ADDRESS:2446 S ST ANDREWS PLACETELEPHONE:
(323) 731-0641
CITY:LOS ANGELESSTATE: CAZIP CODE:
90018
CAPACITY:51CENSUS: 36DATE:
10/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:32 PM
MET WITH:Edguardo GalangTIME COMPLETED:
03:33 PM
NARRATIVE
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Licensing Program Analyst's (LPA) Mario Leon conducted an unannounced Annual required visit with a primary focus on infection control measures. LPA was met by Eguardo Galang, and the purpose of today’s visit was explained. The facility is licensed to serve 51 elderly clients (age 60+) and is licensed to support 38 Non-Ambulatory and 13 Bedridden Residents. The facility has an approved Hospice Waiver on file for 8 Residents. There are currently four (0) Residents on Hospice and zero (0) Residents are receiving wound care treatment.

The facility is located in a residential area. The physical plant consists of the following areas: Receptionist Area, LVN Office, Cinema, Game room, Kitchen. The facility’s latest fire inspection was unable to be located by Los Angeles County Fire Department. Administrator will send the fire clearance when it has been found. The front grounds of the facility is well landscaped and has a leveled walkway to the entrance.

LPA Leon toured random resident rooms, bathrooms, living /activity rooms, commercial kitchen, dining room, and outdoor area. There are two outdoor common areas with patio tables and chairs available for use and an outdoor patio. The bathrooms were observed to be clean and operational w/ grab bars. The hot water temperature through out the facility was measured between 120.9-126.3 degrees F. The facility has central air and heating accommodations.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff and residents, sanitizing stations throughout the facility. LPA observed staff and residents were wearing face coverings, personal quarantine rooms and required postings throughout the facility. LPA observed the facility has an ample 30-day supply of Personal Protective Equipment (PPE).

See LIC 809C
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Mario LeonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: ST JOHN GRANDE
FACILITY NUMBER: 198601817
VISIT DATE: 10/26/2022
NARRATIVE
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While touring the dining room/kitchen area; LPA observed these areas to be clean and well maintained. LPA observed ample food supply of two (2) days of perishables and seven (7) days of non-perishables. Storage areas for cleaning solutions, toxins, knives, and hazardous items were secured and made inaccessible to Residents in kitchen.

LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

During today’s visit there was one (2) deficiencies observed, see LIC 809D.

Exit interview held. A copy of the report was provided to Edguardo Galang

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Mario LeonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/26/2022 03:09 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: ST JOHN GRANDE
FACILITY NUMBER: 198601817

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on Licensing Program Analysts observation, the licensee did not comply with the section cited above in "(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

Public bathroom on 2nd floor measured at 126.3 F, 120.9 F in resident room 215 and 125.2 F in model room 306 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/07/2022
Plan of Correction
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Administrator will submit photos of proper temperature change.
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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"(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:
POC Due Date: 11/07/2022
Plan of Correction
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Administrator was unable to locate the fire clearance, but will send updated copy after receiving.

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: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Mario LeonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2022
LIC809 (FAS) - (06/04)
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