198603285-12-12-2023-28-AS-CWOG-CYG2D3-20231212161741

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603285
Report Date: 12/12/2023
Date Signed: 12/12/2023 04:18:15 PM

Document Has Been Signed on 12/12/2023 04:18 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	ST. JUDE'S ELDER CARE IV		FACILITY NUMBER:	198603285
ADMINISTRATOR:	RAGANO, SCOTT		FACILITY TYPE:	740
ADDRESS:	536 CHARVERS AVENUE		TELEPHONE:	(909) 263-3787
CITY:	WEST COVINA	STATE: CA	ZIP CODE:	91791
CAPACITY:	6	CENSUS: 5	DATE:	12/12/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Rita Regis Garcia		TIME COMPLETED:	04:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Wong conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Caregiver Chris Tan and Rita Regis Garcia. Administrator Judith Ragano arrived shortly after. The facility is licensed for 6 age range 60 and over. 6 non-ambulatory and approved hospice waiver for 6. Currently one resident is on hospice and two residents are on Home Health. The following 12 (CARE) tool domains were utilized during the inspection: Infection Control, Operational Requirements, Physical Plant/Environment Safety, Staffing, Personnel Records/Staff Training, Resident Records/Incident Reports, Planned Activities, Food Service, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs. 1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. 2. Operational Requirement: The Infection Control Plan has been added to the Operation Plan. The facility has a Dementia Waiver in place. A Hospice Waiver for 6 residents is approved. Liability Insurance is updated and in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place. 2. Physical Plant and Environmental Safety: The facility is a single story house and located in a residential neighborhood area. The facility has a small living room, big living room, dining area, kitchen, five residents bedrooms, three bathrooms, one live in staff room and a detached garage. Residents Bedroom#1- #4 has one bed, one chair, one night stand, one drawer, required beddings and sufficient lighting and closet space. Bedroom#5 has two beds, two drawers, two night stands, two chairs, required beddings and sufficient lighting and closet space. (See LIC 809C for continuation)

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ST. JUDE'S ELDER CARE IV	FACILITY NUMBER: 198603285
	VISIT DATE: 12/12/2023

NARRATIVE

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The residents' bathrooms are clean, sanitary and in a good working condition. The residents bathrooms also have the required non-skid mat and grab bar. The hot water temperature tested in between the bathrooms were tested 105 and 108.1 degrees F which are within the title 22 regulation. All the appliances in the kitchen and living room are working properly. All the knives and sharp utensils are stored and locked in the medication cabinet in the kitchen. The cleaning supplies and other chemicals are stored and locked in the laundry room. The walkway, passageway and patio are free of obstruction. The facility has a pool in the backyard but it's secured with a fence and locked. The fireplace is also adequately screened. LPA also inspected the carbon monoxide detector and is mounted on the wall between the dining area and the small living room and it's working well.

4. Staffing: The facility has sufficient staffing in the facility to provide care and supervision to the residents .

5. Personnel Records-Staff Training: All the staff files are stored in the medication cabinet in the kitchen. All the staff in the facility are over 18 years old, fingerprint cleared and associated with the facility. LPA inspected three (3) staff files and they all have the required documents including: employee application, health screening, TB test result, Updated first aid certificate and CPR and required training hours. The facility administrator Judith Ragano and her administrator certificate expired 11/9/2023 and currently her administrator certificate is pending with the CCL since 09/01/2023.

6. Resident Records-Incident Reports: A total of five (5) resident files were reviewed. They contained admission agreements, Physician's Reports, Pre-Appraisal, Appraisal, TB clearance, Functional Capability Assessment, Physician's Orders, medical consent, and medication records.

7. Resident's Right/Information: RCFE complaint poster and Personal rights were observed posted and they are all posed on the board near the entrance way. The facility would provide internet service with at least one internet access device for the residents to use video call with their families or primary physician.

8. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed.

9. Food Service: No resident is currently on any modified diet. Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. All the food in the kitchen are stored properly.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ST. JUDE'S ELDER CARE IV	FACILITY NUMBER: 198603285
	VISIT DATE: 12/12/2023

NARRATIVE

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10. Incidental Medical and Dental: The medication is centrally stored and locked in the medication cabinet in the kitchen. Five (5) centrally stored resident medications were reviewed; which contained 30-day supply of medications. Facility will provide transportation to resident for medical and dental appointment if needed.

11. Disaster Preparedness: The last fire drill was conducted on 11/9/23. Records of resident Appraisal and Needs services plans are part of Emergency training. The facility has an updated Emergency Disaster Plan (LIC610E) and dated on 12/12/23. The facility has two alternative temporary shelter location.

12. Resident with Special Health Needs: Two (2) residents are receiving home health services. One (1) receive hospice care. No resident is currently on postural support. Half and full bed rails for mobility assistance were observed in resident rooms with physician order. Individual Service Plans and Appraisals are on file. No residents have prohibited health conditions.

No deficiencies were observed during the visit.

Exit Interview Conducted and a copy of the report was provided to Caregiver Rita Regis Garcia.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

LIC809 (FAS) - (06/04)

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