198603323-7-6-2023-28-AS-RORN-CUCRJE-20230803130348

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603323
Report Date: 07/06/2023
Date Signed: 07/06/2023 10:14:33 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/14/2023 and conducted by Evaluator Christine Wong

COMPLAINT CONTROL NUMBER: 28-AS-20230614144929

FACILITY NAME:	ST JOHN'S HOME FOR THE ELDERLY		FACILITY NUMBER:	198603323
ADMINISTRATOR:	MCGEE, JAMES & JENNIFER		FACILITY TYPE:	740
ADDRESS:	3203 E CAMERON AVE		TELEPHONE:	(951) 532-4644
CITY:	WEST COVINA	STATE: CA	ZIP CODE:	91791
CAPACITY:	0	CENSUS: 0	DATE:	07/06/2023
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:			TIME COMPLETED:	10:20 AM

ALLEGATION(S):

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Staff did not provide resident's records to authorized representative.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA)Christine Wong conducted a “Subsequent” visit to ascertain additional information regarding the above-mentioned allegation(s) and for the purpose of rendering the findings. LPA arrived at the facility of St. James Home of the Elderly #197603736 located at 1042 Claraday Street Glendora CA 91740 because the facility for which this complaint was filed under St John's Home For The Elderly #198603323 located at 3202 E Cameron Ave West Covina CA 91791 closed on 06/08/23 due to a Change of Ownership. James & Jennifer McGee is the licensee of record for both of the above mentioned facilities. LPA spoke to James McGee over the phone and explained the reason for today's visit. Licensee indicated he will not be able to attend today's visit.

The investigation consisted of the following: On 6/20/23, LPA conducted an initial 10-day complaint and interviewed licensee on the phone and obtained Resident#1(R1) documents from licensee via email.

(See LIC 9099C for continuation)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230614144929

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/06/2023

NARRATIVE

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The investigation revealed of the following: Allegation "Staff did not provide resident's records to authorized representative. " LPA interviewed licensee and reported that facility was served a letter which was prepared by an attorney's office three weeks ago. Licensee indicated that the requested documents were sent over on June 14th, 2023 via email. LPA reviewed the letter that was served to the facility from the attorney's office and the letter was dated May 16, 2023 which indicates that facility took almost a month to submit the request records. Additionally, licensee did not submit R1's complete facility record. It included the identification and emergency information, physician report, admission agreement, addendum to the condition of eviction, consent for emergency medical treatment, client/resident personal property and valuables facilities for the elderly, but was missing resident appraisal (LIC603A) and record of centrally stored prescribed medication for each resident and record of medication destruction, Centrally Stored Medication and Destruction Record (LIC622).

Based on the interviews conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Per California Code of Regulations, Title 22, deficiencies will be cited on the LIC9099-D.

An exit interview conducted with Licensee and but due to licensee was not available to sign the report and a copy of the report and appeal right were given to the staff at St. James Home of the Elderly. A copy of this report will also be mailed to the mailing address on file for St. John's Home For the Elderly.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230614144929

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/06/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/13/2023 Section Cited CCR 87468.2(a)(19)	1 2 3 4 5 6 7	87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, .................. the following personal rights:(19) To have prompt access to review all of their records and to purchase photocopies of their records.	1 2 3 4 5 6 7	The licensee will send the required documents to the required party.
	8 9 10 11 12 13 14	Photocopied records shall be provided within two (2) business days and at a cost that does not exceed the community standard for photocopies. The requirement was not met as evidenced by: Licensee did not send the required documents within 2 business days	8 9 10 11 12 13 14
Type B 07/13/2023 Section Cited CCR 87506(c)(1)	1 2 3 4 5 6 7	87506 Resident Record (c)All information and records obtained from or regarding residents shall be confidential. (1) The licensee shall be responsible for storing active and inactive records and for safeguarding the confidentiality of their contents. The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative.	1 2 3 4 5 6 7	The licensee will submit the complete record to the authorized representative.
	8 9 10 11 12 13 14	The requriement was met as evidenced by: Record review, Licensee did not submit the complete record to the required party.	8 9 10 11 12 13 14

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: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

LIC9099 (FAS) - (06/04)

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