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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603370
Report Date: 11/19/2020
Date Signed: 11/24/2020 11:03:55 AM

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 JULES CARE VILLAFACILITY NUMBER:
198603370
ADMINISTRATOR:DAVID, FERNAN F.FACILITY TYPE:
740
ADDRESS:19229 ALMADIN AVETELEPHONE:
(714) 617-0599
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY:6CENSUS: 0DATE:
11/19/2020
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Fernan David, Applicant/AdministratorTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Patricia Rivas initiated a pre-licensing visit via Teams Meetings. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s pre-licensing visit was conducted via Teams Meetings with Applicant Fernan David.
An application was submitted to Community Care Licensing Department (CCLD) on 05/18/20 for an initial application of an Residential Care Facilities for the Elderly (RCFE) to serve adults ages 60 and over. The facility has a Hospice Waiver for three (3) residents. The requested capacity is for six (6) residents (4)-non-ambulatory residents. Bedroom # 3 &4 are designated as the non-ambulatory room with an exit door to the exterior physical plant. Structure: Facility is a single story home consisting of four (4) bedrooms, one of which is a staff room, two (2) full bathrooms, kitchen, dining room, and living room. A garage will be used for storage. Front yard is landscaped with grass. The home has a backyard area with shaded patio furniture. Bedroom Clients: Four(4)) rooms are shared One is a staff room. Bathrooms: Have a working toilet, wash basin, bathtub. Grab bars and non slip mats in place .Linens & Hygiene Supplies: . Adequate supply of linens Emergency Phone Numbers, Exit Plan: Emergency numbers are posted and readily available for review. . Facility has a land line telephone. Food Service: Dishes, cups, and flatware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery, and other sharp kitchen utensils were observed locked and inaccessible.
Smoke Detectors: There are electrical & inter-connected smoke detectors located in all bedrooms, common areas, and hallways. Carbon monoxide detector is operational. Appliances: Refrigerator, microwave, and ware in working condition. The stove burners, and dishwasher were operable. The residence is equipped with central air and heating throughout the facility. Toxins: Cleaning supplies, and toxins are locked only accessible to staff. Laundry detergents, and toxins are stored in the garage; licensee stated it will only be accessible to staff.
***See LIC 809C for continuation of report.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Pat RivasTELEPHONE: (323) 213-1135
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2020
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 JULES CARE VILLA
FACILITY NUMBER: 198603370
VISIT DATE: 11/19/2020
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Water Temperature: Hot water was tested in all bathrooms, ; water temperature temperature did NOT measure within normal limits 105 degrees Fahrenheit (40.5 degrees C) and not more than 120 degrees Fahrenheit (48.8 degrees C); it was too high measuring at 122 degrees. Medication, First-Aid Kit & Book: was available. Designated centrally stored medications are stored in credenza.. Clients & Staff Files: Designated area for files will be locked and inaccessible. Applicant will not handle cash resources of residents. Pools/Jacuzzi & Pets: No bodies of water and no pets on these premises. Fire Clearance: Fire clearance was granted on 10/02/2020 for two (4) non-ambulatory, and two(2) ambulatory residents, with no delayed egress or locked perimeter. Component III: Component III was conducted..

The following items must be corrected and a follow up visit is scheduled for November 18, 2020 has been scheduled.

1.. Hot water temperature to measure within 105 and 120 for 3 days. Certification to be completed by administrator and sent to LPA..
3. Install shrubbery near entry ramp in order to secure ramp, remove loose bricks.
4. Obtain Sufficient chairs.
5 Change hot and cold water lines in bathroom #2 inside bedroom #3 to have access on the right for cold water and access on the left for hot water.

Items to be completed by 11/25/2020. Certification and invoices and pictures to be sent to LPA by plan of correction date.

A hard copy of the report was emailed. Staff was instructed to sign the LIC 809 reports and return to LPA. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.

SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Pat RivasTELEPHONE: (323) 213-1135
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2020
LIC809 (FAS) - (06/04)
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