198603370-1-6-2023-28-AS-ACAN-CMTRPX-20230106121242

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603370
Report Date: 01/06/2023
Date Signed: 01/06/2023 12:12:49 PM

Document Has Been Signed on 01/06/2023 12:12 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	ST JULES CARE VILLA		FACILITY NUMBER:	198603370
ADMINISTRATOR:	DAVID, FERNAN F.		FACILITY TYPE:	740
ADDRESS:	19229 ALMADIN AVE		TELEPHONE:	(714) 617-0599
CITY:	CERRITOS	STATE: CA	ZIP CODE:	90703
CAPACITY:	6	CENSUS: 2	DATE:	01/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Caregiver: Alan Punsalan		TIME COMPLETED:	12:25 PM

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Licensing Program Analyst (LPA) Ashley Calderon conducted an unannounced Required One (1) year - Inspection to this facility and met with staff Alan Punsalan, who assisted with the visit. 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, 0 residents currently on Hospice Plan.

LPA Calderon and Alan toured and inspected the facilities physical plant including: 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.

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, living room , attached garage used for storage and is inaccessible to residents and a front and back yard area. Doors have an alarmed system for safety of resident with Dementia.

The bathrooms are clean and operational with 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 and living room were clean and properly furnished , no obstructions in pathways/ hallways. 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.All mandated documents are posted in a prominent place.

Continuation LIC 809-C...

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2023

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: 01/06/2023

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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, LPA observed no bodies of water were observed and shaded area is provided.

LPA Calderon later met with Administrator David Fernan and conducted the infection control domain tool. David stated Fire drill was completed December 2022. LPA Calderon reviewed two residents medication and medication log with David and caregiver Diana Fernando. Medications are centrally stored in a locked cabinet, no medication errors were found.

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: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2023

LIC809 (FAS) - (06/04)

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