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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603285
Report Date: 11/08/2022
Date Signed: 11/08/2022 01:40:39 PM


Document Has Been Signed on 11/08/2022 01:40 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. 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:
11/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Judy Regano TIME COMPLETED:
01:50 PM
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Licensing Program Analyst (LPA) Christine Wong and Program Clinical Consultant Toni Rivera conducted an unannounced annual required visit. LPA met with Caregiver Rita Regis Garcia and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LP observed the facility plant, COVID-19 procedures, observed food supply, and reviewed resident and staff files. Shortly after the administrator Judith Ragano arrived and assisted with the visit.

Facility is a single story house and located in a residential neighborhood area. The facility includes kitchen, five resident bedrooms, dining area, living room, TV room, staff bathrooms, two residents bathrooms and a detached garage. The outdoor facility has a patio, a grass area, a pool (large body of water) but its gated. All five residents bedrooms were toured. Bedroom#1- #4 has one bed, one chair, one night stand, required bed linen and furniture and sufficient lighting and closet space. Bedroom#5 has two beds, two chairs, two night stands, required bed linen and furniture and sufficient lighting and closet space. All two residents' bathrooms were toured. They are all clean, sanitary and in a working condition. Both bathrooms have the required grab bars and non-skid mats. The hot water temperature was tested in two bathrooms were 116.9 and 117.1 degrees F which is within Title 22 regulation. The refrigerator and kitchen pantry has sufficient for two days perishable and seven days non perishable food supply. All the kitchen appliances are working properly. The common area such as living room, TV room and dining area have the required furniture. The front and back yard are maintained well.

LPA reviewed 6 resident emergency contact information and they are all updated.. LPA also reviewed two staff files to confirm health screenings and fingerprint clearances. All residents have at least 30 days of supply of medication and incontinent supplies.

Exit Interview conducted. A copy of the report and appeal rights will be provided to the administrator Judith Ragano.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2022
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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