198603344-11-4-2022-28-AS-VMAO-CKUPUA-20221104113714

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603344
Report Date: 11/04/2022
Date Signed: 11/04/2022 11:37:23 AM

Document Has Been Signed on 11/04/2022 11:37 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. JUDE'S ELDER CARE II		FACILITY NUMBER:	198603344
ADMINISTRATOR:	RAGANO, SCOTT		FACILITY TYPE:	740
ADDRESS:	502 SOUTH DARWOOD AVENUE		TELEPHONE:	(909) 263-3787
CITY:	SAN DIMAS	STATE: CA	ZIP CODE:	91773
CAPACITY:	6	CENSUS: 5	DATE:	11/04/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Judy Ragano- Licensee		TIME COMPLETED:	11:45 AM

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) V. Maldonado made an unannounced visit to the facility for the purpose of conducting the required annual inspection using the Infection Control Evaluation Tool. LPA Maldonado met with staff Robby Sawada and explained the purpose for the visit. LPA observed the physical plant with staff, COVID-19 procedures, reviewed residents' medications, observed food supply, and reviewed resident and staff files. Facility has submitted a mitigation plan and the plan has been approved. Licensee Judy Ragano arrived shortly after and assisted with the visit. The facility is a home located in a residential area and is licensed to serve 6 residents, ages 60 and over. The license is approved for (5) non-ambulatory residents, (1) bedridden resident, and a hospice waiver approved for (6) residents and approved dementia care plan. The The home consists of (4) resident bedrooms, (2) bathrooms, kitchen, dining room, living room, visitor/office room, laundry room, a shaded patio in the backyard, and an attached garage. (2) resident bedrooms are shared, (1) is currently vacant, and (1) is private. LPA observed all resident bedrooms to have the required furniture, linens, and closets with additional storage space. All entrances/exits were observed to have operating auditory devices, during the visit. All walkways and pathways were observed to be free of obstructions and hazards. The food supplies in the facility was observed to be a variety of nutritious foods. The required 2-day of perishables and 7-day non-perishables foods was observed in the kitchen and garage refrigerators, as well as the kitchen pantry. All cleaning supplies/toxins were observed to be locked and inaccessible in a cabinet under the kitchen sink and all sharps were locked and inaccessible in a drawer in the kitchen next to the sink. A fire extinguisher was observed in the laundry room to have a recent inspection and be fully charged. LPA observed the bathrooms in the home to have a toilet, shower, and wash basin- all in good repair and operational. The water temperature was tested and measured at 113.5F in bathroom#1 and 116.8F in bathroom#2. (Report Continued on LIC809-C...)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022

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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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. JUDE'S ELDER CARE II	FACILITY NUMBER: 198603344
	VISIT DATE: 11/04/2022

NARRATIVE

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Smoke/carbon monoxide detectors were observed throughout the facility. They were interconnected and operational upon testing. The First Aid Kit was observed to have the required items and First Aid Manual.
LPA did not observe COVID-19 signange posted throughout the facility to promote hand washing, mask wearing, cough/sneeze etiquette, and social distancing. A sufficient 30-day supply of Personal Protective Equipment (PPE) was observed in the garage and throughout the facility, accessible to residents in care. There is a central entry point designated for temperature/symptom screening. All hand washing stations were observed to have sufficient soap and paper towels.

LPA reviewed 5 resident files. Files were complete and included appraisals, physician's reports, medical consent. LPA also reviewed 2 staff files to confirm health screenings, fingerprint clearances and training. LPA reviewed 5 residents' medications. Medications are documented properly and given as prescribed.

There was a technical advisory given to the facility for failure to have the COVID-19 signage posted throughout the facility. This is a requirement for COVID-19 procedures.

Per California Code of Regulations and Health and Safety Codes, no deficiencies were cited during today's visit.

An exit interview was conducted with licensee Judy Ragano and a copy of the report and Technical Advisory was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022

LIC809 (FAS) - (06/04)

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