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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603285
Report Date: 12/15/2021
Date Signed: 12/15/2021 11:23:24 AM

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. JUDE'S ELDER CARE IVFACILITY NUMBER:
198603285
ADMINISTRATOR:RAGANO, SCOTTFACILITY TYPE:
740
ADDRESS:536 CHARVERS AVENUETELEPHONE:
(909) 263-3787
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY:6CENSUS: 6DATE:
12/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Rita Regis (Caregiver)TIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Kruz Long conducted a site visit for the annual inspection. Upon arriving at the facility LPA met with Rita Regis (Caregiver) and explained the purpose of the visit. A short time later, Judith Ragano (Administrator) arrived to the facility and assisted with the visit. The facility is licensed to serve age range 60 and over. 6 non-ambulatory. Approved hospice waiver for 6.

The facility is located in a residential area. A tour of the single-story facility includes: Living room, dining area, kitchen, laundry area, 5 resident bedrooms, 1 staff bedroom, 3 bathroom, 1 detached pool bathroom and an attached garage/storage..

During today's visit, LPA observed the following: Facility is not operating over capacity or beyond any conditions and limitation on the license. Pools is appropriately secured. No firearms on the premises. Facility maintain a comfortable temperature for residents. All outdoor and indoor passageways are kept free of obstruction. Licensee ensure grab bars for each toilet, bathtub and shower used by residents. Bathtub or shower have non-skid mats or strips. The total daily diet is of the quality and in the quantity necessary to meet the resident’s needs. LPA observed a minimum of one week supply of nonperishable foods and 2 days of perishable foods. All readily perishable foods or beverages capable of growth of micro-organisms is stored in covered containers at appropriate temperature. The facility has sufficient and competent staff to provide the services needed to meet resident needs. Staff assisting residents with ADLs has required training. Criminal Record Clearance for all required persons is associated to the license. Staff responsible for direct care and supervision have current first aid training. Facility have a disaster and mass casualty plan. A certified administrator is on the premise for a sufficient number of hours to manage and oversee the business operation. Medications are given per the physician’s directions. There is a signed and dated written order from a physician for every prescription and nonprescription PRN medication. Centrally stored medicines is kept in a safe and locked place. Smoke detectors are operational. Hot water temperature measured at 138.5 degrees F in bathroom #1.

Per Title 22 Regulations, the deficiencies observed are documented on LIC809D. Failure to correct the deficiencies may result in civil penalties.

An exit interview was conducted and a copy of this report and appeal rights provided to Judith Ragano.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz LongTELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ST. JUDE'S ELDER CARE IV
FACILITY NUMBER: 198603285
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)


This requirement is not met as evidenced by: Hot water temperature measured at 138.5 degree F in bathroom #1.
Deficient Practice Statement
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Based on LPA's 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.
POC Due Date: 12/16/2021
Plan of Correction
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LIcensee shall adjust water temperature and provide proof to the department when water temperature measures within Title 22 guidelines.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz LongTELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2021
LIC809 (FAS) - (06/04)
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