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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603285
Report Date: 10/07/2024
Date Signed: 10/07/2024 01:43:36 PM


Document Has Been Signed on 10/07/2024 01:43 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 IVFACILITY NUMBER:
198603285
ADMINISTRATOR:RAGANO, SCOTTFACILITY TYPE:
740
ADDRESS:536 CHARVERS AVENUETELEPHONE:
(909) 263-3787
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY:6CENSUS: 6DATE:
10/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:47 AM
MET WITH:Judy Ragano, licensee TIME COMPLETED:
01:58 PM
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Licensing Program Analyst (LPA) Alberto Lopez made unannounced visit for required annual inspection. LPA met with Staff Chris Tan and Licensee Judy Regano arrived a short time later and assisted with the visit.

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 nightstands, two chairs, required beddings and sufficient lighting and closet space. 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 and kitchen were tested 106.1 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 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 was not locked. The fireplace is 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.

(Continued on 80C)

SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


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: 10/07/2024
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4. Staffing: The facility has sufficient staffing, and the night supervision staff did receive planned emergency training.

5. Personnel Record-Training: All the staff files are maintained in the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. All the direct care staff received Medication Management Training. The first aid training certificates for staff is current.

6. Resident Records-Incident Reports: Resident files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan.


7. Resident Rights-Information: The Complaint, ombudsman and CCLD poster and Residents personal rights are posted by the main entry. Visiting hours were posted at facility.
8. Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability.
9. Food Service: The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be very clean and sanitary. The food is properly stored in the refrigerator (clean, labeled and well maintained). Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept very clean and free from rodents.
10. Incidental Medical and Dental: The medication is centrally stored and locked in the medication cabinet in the kitchen. Four (4) centrally stored resident medications were reviewed, which contained 30-day supply of medications. R4 did not have doctor’s order or label. Facility will provide transportation to resident for medical and dental appointment if needed.
11. Disaster Preparedness: The last fire drill was conducted on 10/01/2024. 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.

Deficiencies cited on 809D, Technical Advisory provided. Exit interview, copy of report and appeal rights provided.

SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/07/2024 01:43 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
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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(e)
Personal Accommodations and Services
(e) Facilities providing services to residents who have physical or mental disabilities shall assure the inaccessibility of fishponds, wading pools, hot tubs, swimming pools or similar bodies of water, when not in active use by residents, through fencing, covering or other means.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, side pool gate was accessible, the licensee did not comply with the section cited above in 6 out of 6 residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/07/2024
Plan of Correction
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*Staff secured gated during inspection*** NO FURTHER ACTION REQUIRED.
Type B
Section Cited
CCR
87606(c)
Care of Bedridden Residents
(c) To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. R1 LIC 602 dated 08/29/2024 states resident is bedridden which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/11/2024
Plan of Correction
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Licensee was able to change LIC602 to reflect client as non-ambulatory by client's doctor. ***NO FURTHER ACTION REQUIRED***
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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4