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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603370
Report Date: 11/30/2021
Date Signed: 11/30/2021 12:12:00 PM

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: 2DATE:
11/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Staff / Alan Punsalan
and Administrator Fernan David		TIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced Required One (1) year - Inspection to this facility and met with staff Alan Punsalan, who assisted with the visit. Shortly after administrator Fernan David arrived. The purpose of the visit was explained. The facility is licensed to serve 6 (six) ambulatory residents ages 60 and over of which 4 (four) may be non-ambulatory. Facility is approved to retain 3 residents on hospice.

LPA Nune Margaryan inspected the physical plant including but not limited to the kitchen, dining and living room, bedrooms, bathrooms, laundry area (located in the garage), and outside areas of the facility to ensure compliance with Title 22 regulations. LPA also conducted the infection control domain tool.

Facility is a single story home consisting of four (4) bedrooms, 1(one) of which is a staff room, two (2) full bathrooms, kitchen, dining room, and living room. The attached garage use for storage. Front yard is landscaped with grass. The home has a backyard area with shaded patio furniture.

The bathrooms are clean and operational w/grab bars and non-skid surface/mats in place. The hot water temperature was tested throughout the facility and maintained within the required range of 105-120*F.

The common areas (dining room, living room) were clean and properly furnished. Resident rooms are sanitary and had the required furniture and furnishings. The kitchen was observed for the ability to prepare and serve food. Kitchen appliances are clean and were operating at the time of the visit. Sharps are locked in the kitchen and are inaccessible to residents. LPA observed a sufficient supply of perishables and non-perishables and emergency food supply. Cleaning supplies and toxins are locked and are inaccessible to residents. First Aid kits were inspected and were fully stocked. Medications are centrally stored in a locked cabinet. All mandated documents are posted in a prominent place.

(report continues LIC 809C)

SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune MargaryanTELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021
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: 11/30/2021
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The fire extinguishers observed to be fully charged. Smoke/carbon monoxide detectors were observed to be fully operational. The outdoor area was enclosed, and no bodies of water were observed.

Per California Code of Regulations, Title 22, deficiencies were not observed during the visit. Exit interview conducted and a copy of the report was provided.


SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune MargaryanTELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021
LIC809 (FAS) - (06/04)
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