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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603323
Report Date: 02/17/2023
Date Signed: 02/17/2023 05:00:05 PM


Document Has Been Signed on 02/17/2023 05:00 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 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: 5DATE:
02/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Briana McGee-Administrator TIME COMPLETED:
04:40 PM
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Licensing Program Analyst (LPA) Christine Wong conducted an unannounced annual required visit. LPA met with caregiver Jaznifer Cafuir and explained the reason for the visit. Shortly after, the house manager Barbara Boiston and Administrator Briana McGee arrived and assisted with the visit. LPA used the infection control tool to evaluate the facility. LPA observed the facility plant, COVID-19 procedures, reviewed residents' medications, observed food supply, and reviewed resident and staff files.

The facility is a single story house and located in a residential neighborhood area with a long drive way. The facility include: kitchen, laundry room, dining area, guest/staff bathroom, live in staff bedroom, living room, three residents bedrooms, one resident bathroom and a detached garage. LPA toured all 3 residents' bedrooms and each bedroom has two beds, two night stands, drawer, required bed linen and furniture and sufficient lighting and closet space. The resident bathroom is clean, sanitary and in a good working condition. The bathroom have the required grab-bar and non-skid mat. The hot water temperature in the bathroom tested at 119.1 degrees which is within the required 105-120 degrees F. The refrigerator in the kitchen and kitchen cabinet have two days perishable and seven days non-perishable food supply. All the appliances in the kitchen are working properly. The sharp knives and utensils are locked in the kitchen cabinet. All the cleaning supplies and chemicals are locked in the cabinet in the laundry room and they are inaccessible for the residents. The common area such as living room and dining area and have the required furniture. Passageways are free of obstruction and debris. The front and back yard are maintained well and there's a shaded area with table and chairs in the back patio for resident to utilize.

LPA reviewed 5 resident files to confirm emergency contact is updated. LPA also reviewed 2 staff files to confirm that they both have updated health screenings on their personnel files and they both fingerprint cleared. LPA inspected all 5 clients' medication and the medication are centrally stored and locked in the kitchen cabinet. All residents' medications seems updated and accurate.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2023
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 JOHN'S HOME FOR THE ELDERLY
FACILITY NUMBER: 198603323
VISIT DATE: 02/17/2023
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Facility is currently following COVID 19 recommendations regarding COVID 19 signs throughout the facility, facility is disinfected multiple times a day. The residents' bathroom have sufficient soap, paper towels, and sign.

No deficiencies were observed during the visit.

Exit Interview conducted and A copy of the report was provided to Administrator Briana McGee.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023
LIC809 (FAS) - (06/04)
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