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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603323
Report Date: 03/02/2022
Date Signed: 03/02/2022 11:44:50 AM


Document Has Been Signed on 03/02/2022 11:44 AM - 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 JOHN'S HOME FOR THE ELDERLYFACILITY NUMBER:
198603323
ADMINISTRATOR:MCGEE, JAMES & JENNIFERFACILITY TYPE:
740
ADDRESS:3203 E CAMERON AVETELEPHONE:
(951) 532-4644
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY:6CENSUS: 6DATE:
03/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Barbara Boiston (House Manager)TIME COMPLETED:
12:00 PM
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 Barbara Boiston (House Manager) and explained the purpose of the visit. The facility is licensed to serve age range 60 and over. Approved for 6 non-ambulatory. Approved hospice waiver for 6 Residents.

The facility is located in a residential area. A tour of the single-story facility includes: Living room, kitchen, dining area, 3 Resident bedrooms, 1 Staff bedroom, 2 bathrooms, laundry room 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. There are no pools or bodies of water on the premises. Facility has maintained a comfortable temperature for residents. All outdoor and indoor passageways are kept free of obstruction. Smoke detectors and carbon monoxide detectors area operable. Fire extinguishers are fully charged. Hot water temperature measured at 130.2 degrees F in bathroom #1. Grab bars for each toilet, bathtub and shower used by residents was present. Bathtub or shower have non-skid mats. Minimum of one week supply of nonperishable foods and 2 days of perishable foods was observed. 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. Staff has criminal record clearance. Staff responsible for direct care and supervision have current first aid training. Facility has a disaster and mass casualty plan. Medications are given per the physician’s directions. Centrally stored medicines is kept in a safe and locked place.

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



An exit interview was conducted and a copy of this report and appeal rights provided to Barbara Boiston.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz LongTELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2022
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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Document Has Been Signed on 03/02/2022 11:44 AM - 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: ST JOHN'S HOME FOR THE ELDERLY
FACILITY NUMBER: 198603323

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/02/2022

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


This requirement is not met as evidenced by: Water temperature measured at 130.2 degrees F in bathroom #1.
Deficient Practice Statement
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Based on observations, 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: 03/03/2022
Plan of Correction
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Licensee shall immediately adjust water heater to ensure water temperature falls within 105 degrees F to 120 degrees F in the facility.

Note: Water heater was adjusted at time of visit.
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: 03/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2022
LIC809 (FAS) - (06/04)
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