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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603344
Report Date: 09/28/2026
Date Signed: 09/28/2026 04:10:10 PM

Document Has Been Signed on 09/28/2026 04:10 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ST. JUDE'S ELDER CARE IIFACILITY NUMBER:
198603344
ADMINISTRATOR/
DIRECTOR:		RAGANO, SCOTTFACILITY TYPE:
740
ADDRESS:502 SOUTH DARWOOD AVENUETELEPHONE:
(909) 263-3787
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY: 6CENSUS: 6DATE:
09/28/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Lean Forsee, Assistant Administrator TIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced required annual inspection using the Compliance and Regulatory Enforcement (CARE) Tool. LPA was greeted by facility staff and Lean Forsee, Assistant Administrator, and informed them of the purpose of the visit.

The facility’s fire clearance is approved for six (6) non-ambulatory residents, ages 60 and over, of whom one (1) may be bedridden. The facility also maintains a hospice waiver for six (6) residents.

At the time of the inspection, two (2) residents were receiving hospice care.

Facility Tour & Observations:

Personal Rights postings (LIC 613C and Ombudsman), Complaint Poster (PUB 475), and the nondiscrimination notice were observed posted in a common area. Residents had access to personal space, privacy, and adequate storage for personal belongings. No firearms or weapons were present at the facility.

Physical Plant:

The facility is located in a residential neighborhood and consists of a single-story home with four (4) resident bedrooms, two (2) bathrooms, a living room, family room, kitchen/dining area, and an attached garage with a caregiver corridor, front yard, and backyard. All residents observed contained the required furnishings, including a bed, mattress, linens, dresser, chair, and adequate lighting. During the facility walkthrough, LPA observed a small section of flooring in the living room that was lifting and in need of repair. LPA also observed areas of the walls in some resident bedrooms that needed repair and/or painting. LPA observed that sharps, cleaning supplies, and other toxic substances were inaccessible to residents. Sharps were stored in a secured kitchen cabinet. Cleaning supplies were secured in the locked laundry room and in a secured kitchen cabinet underneath the sink. Bathrooms were observed to be clean and equipped with required safety features, including grab bars near toilets and bathing areas and non-skid mats. Toilets, sinks, and bathing fixtures were observed to be operational. Hot water temperature was observed outside the required regulatory range of 105°F–120°F. (continued on 809C).

David Sicairos
Gabriela Castro
DATE: 09/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 09/28/2026 04:10 PM - It Cannot Be Edited


Created By: Gabriela Castro On 09/28/2026 at 03:38 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ST. JUDE'S ELDER CARE II
FACILITY NUMBER: 198603344

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. During the facility walkthrough, LPA observed a small section of the living room flooring lifting and in need of repair. LPA also observed walls in resident bedrooms that were in need of repair and/or painting which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/16/2026
Plan of Correction
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The facility will repair the lifting section of flooring in the living room to ensure the flooring is maintained in good repair and does not present a potential safety hazard. The facility will also repair and repaint the identified resident bedroom walls. The Administrator will submit photographs and/or documentation demonstrating completion of the repairs to Licensing by the POC due date.
Request Denied
Type B
Section Cited
CCR
87458(c)(1)(A)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis.

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. LPA reviewed R1’s resident file and observed that the file did not contain documentation of a tuberculosis (TB) test which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/16/2026
Plan of Correction
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The facility will obtain the required TB documentation for R1 and maintain a copy in R1’s resident file. The Administrator will submit proof of R1’s TB documentation to Licensing by the POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Gabriela Castro
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2026


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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ST. JUDE'S ELDER CARE II
FACILITY NUMBER: 198603344
VISIT DATE: 09/28/2026
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Extra linens and towels were available and stored in hallway cabinets. Smoke and carbon monoxide detectors were tested and found to be operational. Fire extinguishers were observed and available. No bodies of water were present on the premises. Passageways and exits were observed to be clear and unobstructed. The front and backyard areas were observed to be maintained and contained shaded seating areas for resident’s use.

Food Service:

Refrigerators and freezers were maintained at appropriate temperatures, with refrigerators observed at or below 40°F and freezers at 0°F. The facility maintained a sufficient supply of at least two (2) days of perishable food and seven (7) days of non-perishable food. Fresh produce, proteins, and dry goods were observed and available for resident use.

Health-Related Services & Records:

Three (3) resident files were reviewed. Files contained required documentation, including Admission Agreements, signed consents, Physician’s Reports documenting ambulatory status, and Resident Rights acknowledgments. However, during record review, LPA observed that R1's file did not contain documentation of a current tuberculosis (TB) test.

Three (3) residents’ medications and medication records were reviewed. Medications were observed to be centrally stored and secured in a locked cabinet located near the dining area.

Disaster Preparedness:

The most recent fire/earthquake drill was conducted on August 17, 2026, and corresponding drill logs were available for review. The LIC 610D Emergency Disaster Plan was available for review and was in the process of being updated at the time of the inspection. Emergency supplies, including water, food, flashlights, batteries, and first aid supplies, were observed and available for use in the event of an emergency.

Personnel Records & Training

Three (3) staff files were reviewed and included criminal record clearances, CPR/First Aid, required training and TB screenings.

An exit interview was conducted with Lean Forsee . During the inspection, deficiencies were observed and cited on the attached LIC 809D/809C in accordance with Title 22, Division 6 regulations. A copy of this report, LIC 809D/809C, and appeal rights will be provided.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Gabriela Castro
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2026
LIC809 (FAS) - (06/04)
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