198601817-6-17-2024-11-AS-EGOZ-D6BT4Q-20240617142419

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601817
Report Date: 06/17/2024
Date Signed: 06/17/2024 02:24:24 PM

Document Has Been Signed on 06/17/2024 02:24 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	ST JOHN GRANDE		FACILITY NUMBER:	198601817
ADMINISTRATOR:	SABRINA TUCKER		FACILITY TYPE:	740
ADDRESS:	2446 S ST ANDREWS PLACE		TELEPHONE:	(323) 731-0641
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90018
CAPACITY:	51	CENSUS: 51	DATE:	06/17/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Arjene Aguirre		TIME COMPLETED:	02:30 PM

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On 06/17/24, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced annual required visit using the CARE tool. LPA met with Arjene Aguirre, Assistant Administrator, and the purpose of today’s visit was explained. The facility is licensed to serve 38 non-ambulatory and 13 bedridden residents ages 60 and above and has a hospice waiver approved for 8. Currently there are 51 residents in the facility.

The facility is a three-story structure located in a residential neighborhood. It consists of the following: a receptionist area, clinic/medication room, cinema room, game room, kitchen, dining room, laundry room, staff offices and a large, shaded patio/garden area. LPA and Assistant Administrator toured the physical plant inside and out. Bedrooms 103, 105, 201, 208, 316, 319 were checked. Beds and bedding were in good condition, adequate lighting provided, storage for resident’s personal belongings was observed. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be complying within Title 22 regulations and were clean and operational. The water temperature measured between 105.0 F and 120.0 F in all bathrooms. A comfortable temperature is maintained in the facility. LPA observed the facility to be clean and appropriately furnished at the time of visit.

The kitchen was inspected and observed to be within Title 22 regulations. Sharps, toxins, cleaning solutions, hazardous items, and medications were secured and inaccessible to residents. Medications were centrally stored and properly locked. Smoke detectors and carbon monoxide detectors were operational and working properly. Fire extinguishers were fully charged. LPA observed a stocked First Aid kit along with manual locked and inaccessible to residents. Outside grounds were toured and no bodies of water were observed. Walkways around the facility were clear of hazards.

Continued on LIC809-C

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Elvira Gonzalez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024

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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: ST JOHN GRANDE	FACILITY NUMBER: 198601817
	VISIT DATE: 06/17/2024

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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents. There are sanitizing stations in common areas and restrooms. LPA observed all mandated inspection control postings throughout the facility.

During this inspection LPA did not observe any deficiencies, therefore no citations were issued at this time.

An exit interview was conducted, and a copy of the Report and Appeal Rights was provided to Assistant Administrator Arjene Aguirre.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Elvira Gonzalez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024

LIC809 (FAS) - (06/04)

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