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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603370
Report Date: 12/17/2024
Date Signed: 12/17/2024 11:52:57 AM

Document Has Been Signed on 12/17/2024 11:52 AM - 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 JULES CARE VILLAFACILITY NUMBER:
198603370
ADMINISTRATOR/
DIRECTOR:		DAVID, FERNAN F.FACILITY TYPE:
740
ADDRESS:19229 ALMADIN AVETELEPHONE:
(714) 617-0599
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 2DATE:
12/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Alan Punsalan CaregiverTIME VISIT/
INSPECTION COMPLETED:
12:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christian Gutierrez conducted an unannounced annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA was met by Caregiver Alan Punsalan at approximately 9:00 AM and explained reason for visit. House manager Maria Quiogue arrived shortly.

Facility is licensed to serve six (6) residents over 60 years old four (4) can be non-ambulatory. Hospice waiver approved for Three (3). The facility is in a residential area, and it is a one-story family home. A tour of the single-story facility included the living room, kitchen, dining room, three (3) client bedrooms, one (1) staff room, 2 bathrooms, front yard, backyard, attached garage.

LPA toured the facility and observed the following: Each resident’s bedroom has the required furniture and bedding. R1 did not have physician orders for bed rail deficiency cited. There is extra clean linen and towels in garage cabinet. Smoke / carbon monoxide detectors were observed in each room and throughout the facility and are properly operating. The facility has two (2) fully charged fire extinguishers which is kept in kitchen and hallway. Cleaning supplies and toxic substances are inaccessible locked in cupboards in kitchen. Freezers are maintained at a temperature of 0-degree F and the refrigerators at a maximum of 40 degrees F. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. There are no firearms or weapons stored at the facility. The hot water temperature in the bathrooms were measured between the required range of 105-120 degrees F. Bathrooms had required grab bars and nonskid mats. The facility does not have a swimming pool or bodies of water on the premises There is a shaded seating area for the residents located in the backyard. Passageways and exits are free of obstruction. Garage has an extra freezer and supplies.

SEE LIC 809C

Tony VasalloTELEPHONE: (323) 981-3977
Christian GutierrezTELEPHONE: 323-981-3984
DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2024
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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Document Has Been Signed on 12/17/2024 11:52 AM - It Cannot Be Edited


Created By: Christian Gutierrez On 12/17/2024 at 10:58 AM
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 JULES CARE VILLA
FACILITY NUMBER: 198603370

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208.

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 facility did not have infection control plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/31/2024
Plan of Correction
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House manager will email 9282 infection control plan to LPA by POC due date.
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

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 Administrator did not have file at facility. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/31/2024
Plan of Correction
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House manager will email all documents to LPA by 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.
SUPERVISOR'S NAME:Tony Vasallo
TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME:Christian Gutierrez
TELEPHONE: 323-981-3984
LICENSING EVALUATOR SIGNATURE:
DATE: 12/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2024


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 12/17/2024 11:52 AM - It Cannot Be Edited


Created By: Christian Gutierrez On 12/17/2024 at 10:58 AM
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 JULES CARE VILLA
FACILITY NUMBER: 198603370

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)
Resident Records
(b) Each resident's record shall contain at least the following information:

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 in two (2) out of two (2) residents were missing (R1)LIC 601,conset form, personal rights LIC 613, and appraisel needs and service. (R2) missing LIC 602 current physicians report,appraisel needs and service, and LIC 613 personal rights which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/31/2024
Plan of Correction
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House manager will email documents to LPA by POC due date.
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
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Based on record review, the licensee did not comply with the section cited above facility did not have any drill conducted which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/31/2024
Plan of Correction
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House manager will conduct drill with satff and email drill to LPA by 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.
SUPERVISOR'S NAME:Tony Vasallo
TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME:Christian Gutierrez
TELEPHONE: 323-981-3984
LICENSING EVALUATOR SIGNATURE:
DATE: 12/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 12/17/2024 11:52 AM - It Cannot Be Edited


Created By: Christian Gutierrez On 12/17/2024 at 10:58 AM
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 JULES CARE VILLA
FACILITY NUMBER: 198603370

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)
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:

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 R1 did not have physicians order for bed rails which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/31/2024
Plan of Correction
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House manager will obtain physicians order for bed rails and eamil to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Tony Vasallo
TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME:Christian Gutierrez
TELEPHONE: 323-981-3984
LICENSING EVALUATOR SIGNATURE:
DATE: 12/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2024


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 JULES CARE VILLA
FACILITY NUMBER: 198603370
VISIT DATE: 12/17/2024
NARRATIVE
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Three (3) Staff files were reviewed. Administrator did not have file at facility deficiency cited. Two (2) resident files were reviewed and were missing physicians report, consent forms, personal rights LIC 613, and appraisal needs and service. Fire/earthquake drill was not conducted deficiency cited. Infectious control plan was not available. The medications are centrally stored and locked in a cabinet in dining room. LPA reviewed medications for all residents, and they are being administered as prescribed by the physician.

Deficiencies have been noted on LIC 809D under Title 22 Regulations. Exit interview was conducted and a copy of this report, LIC 809D and appeal rights were provided to Maria Quiogue.

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Christian GutierrezTELEPHONE: 323-981-3984
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
LIC809 (FAS) - (06/04)
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