198603370-12-14-2023-28-AS-ACAN-CYJ2YB-20231214164828

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603370
Report Date: 12/14/2023
Date Signed: 12/14/2023 04:51:20 PM

Document Has Been Signed on 12/14/2023 04:51 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: 3	DATE:	12/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:25 AM
MET WITH:	Administrator Fernan David		TIME COMPLETED:	05:00 PM

NARRATIVE

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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 Richard "Rika" Fernando, who assisted with facility tour. At approximately 11:00AM LPA met with Administrator Fernan David to assist with the visit.

The facility is licensed to serve 6 (six) ambulatory residents ages 60 and over of which (4) may be non-ambulatory. Facility is approved to for (3) residents on hospice, currently the facility has (0) residents currently on Hospice Plan.

LPA Calderon and "Rika" toured and inspected the facility. Facility is a single story home, physical plant includes: (3) resident bedrooms and (1) staff bedroom, and (2) bathrooms, kitchen, dining, laundry area (located in the garage), an attached garage and backyard.

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 clean and were observed with appropriate bedding/ linen and furniture. Two (2) residents: Resident #1 and #3 were observed using a hospital bed and 1/2 rails, no physician report was provided, deficiency cited. Resident #2 sleeps in recliner due to personal choice.

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. Cleaning supplies and toxins are locked and are inaccessible to residents.

Temperature maintained at the house was maintained comfortable during the visit.

(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: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

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: 12/14/2023

NARRATIVE

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The fire extinguishers observed to be fully charged. Smoke/carbon monoxide detectors were observed to be fully operational. Administrator was unable to provide documentation on Fire Drill to LPA, deficiency noted.

LPA reviewed training's, Administrator was unable to provide training in-services, deficiencies were cited.

LPA reviewed resident files, Resident #1, #2 and #3 did not have Appraisal Needs and Service Plan in resident's file during review, deficiency cited. LPA was unable to review staff files, Administrator informed LPA staff files weren't present during facility visit (missing training and personnel records), deficiencies cited. LPA used staff roster LIC500 and verified staff clearance on Facility Personnel Report Summary, all staff were cleared and associated.

Medication was reviewed at 2:15pm, Resident #1 , Resident #2 and Resident #3 did not have a list of centrally stored medications.

LPA toured backyard and ramps, pathways and were safe and was observed clean/ no bodies of water were observed and shaded area is provided.

Liability Insurance was not provided to LPA, deficiency cited.

LPA conducted interview with resident #2 and did (2) attempt interviews.

Administrator Certification submitted certification renewal documentation's in a timely manner, Administrator is waiting for certification with CCLD- Administrator Certification Section.

Per California Code of Regulations, Title 22, deficiencies were observed during the visit and LPA issued citations. LPA Calderon provided copies of LIC809, LIC809-C, (5) 809-D pages and Appeal Rights. 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: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/14/2023 04:51 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(g)

Personnel Records

(g) All personnel records shall be maintained at the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview with Administrator, Administrator stated not having any staff files at the facility, the licensee/ facility did not comply with the section cited above in [3] out of [3] persons, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/15/2024
	Plan of Correction
1 2 3 4	Administrator will submit LIC501, LIC503 with T/B, LIC9052 Employee Rights to LPA Calderon's email.

Type B

Section Cited

HSC

1569.695(b)

Other Provisions

(b) A facility shall provide training on the plan to each staff member upon hire and annually thereafter. The training shall include staff responsibilities during an emergency or disaster. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview with Administrator, Administrator stated not having training in-services logs for each staff at the facility, the licensee/ facility did not comply with the section cited above in [3] out of [3] persons, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/15/2024
	Plan of Correction
1 2 3 4	Administrator will conduct training requirements to staff and provide LPA Calderon copies of in-services, with training notes, and signature log sheet.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/14/2023 04:51 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview with Administrator Fernan David informed LPA Fire Drill in-service training are not documented , the licensee did not comply with the section cited above in [3] out of [3] persons, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/29/2023
	Plan of Correction
1 2 3 4	Administrator will conduct a fire drill and provide in-service training and information covered to LPA Calderon via email.

Type B

Section Cited

HSC

1569.695(e)(1)

Other Provisions

(e) A facility shall have all of the following information readily available to facility staff during an emergency: (1) A resident roster with the date of birth for each resident. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview with Administrator Fernan David , the licensee/facility did not comply with the section cited above in [3] out of [3] persons, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/29/2023
	Plan of Correction
1 2 3 4	Administrator will provide LPA Calderon, a Resident Roster LIC9020 with residents date of birth.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

LIC809 (FAS) - (06/04)

Page: 12 of 15

Document Has Been Signed on 12/14/2023 04:51 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(e)(2)

Other Provisions

(e) A facility shall have all of the following information readily available to facility staff during an emergency: (2) An appraisal of resident needs and services plan for each resident. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview with Administrator Fernan David and during record review of staff files, no files were made available for LPA's review , the licensee did not comply with the section cited above in [3] out of [3] persons which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/29/2023
	Plan of Correction
1 2 3 4	Administrator will locate and send to LPA Calderon an email of Resident #1-#3 Appraisal Needs and Service Plan by due date.

Type B

Section Cited

HSC

1569.695(e)(3)

Other Provisions

(e) A facility shall have all of the following information readily available to facility staff during an emergency: (3) A resident medication list for residents with centrally stored medications. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview with Administrator Fernan David, Administrator stated not having a list of centrally stored medication for residents, the licensee/ facility did not comply with the section cited above in [3] out of [3] persons, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/29/2023
	Plan of Correction
1 2 3 4	Administrator will email Centrally Stored Medication List (LIC622) for all residents in care by POC due date to LPA Calderon email.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

LIC809 (FAS) - (06/04)

Page: 13 of 15

Document Has Been Signed on 12/14/2023 04:51 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87212(b)

Emergency Disaster Plan

(b) The plan shall be subject to review by the Department and shall include: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review when LPA Calderon asked to review Emergency Disaster Plan Administrator informed LPA the Emergency Disaster Plan was not maintained at the facility, the licensee/facility did not comply with the section cited above in [3] out of [3] persons, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/29/2023
	Plan of Correction
1 2 3 4	Administrator will submit Emergency Disaster Plan to LPA Calderon by POC due date via email.

Type B

Section Cited

CCR

87608(a)(3)

Postural Supports

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation during physical tour LPA Calderon observed half bed rails/ hospital beds for resident #1 and resident #3, interview with Administrator, Fernan David informed not having records / not having physician order in place for residents and LPA did not obtain , during resident file record review LPA did not observe physician orders, the licensee did not comply with the section cited above in [3] out of [3] persons, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/29/2023
	Plan of Correction
1 2 3 4	Administrator will obtain physician orders for hospital bed and railings for resident #1 and #3 and will email a copy to LPA via email.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

LIC809 (FAS) - (06/04)

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