198603540-2-4-2022-28-AS-BTAO-CBBT4Z-20220204132446

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603540
Report Date: 02/04/2022
Date Signed: 02/04/2022 01:26:06 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 ELIZABETHS HOME FOR THE ELDERLY		FACILITY NUMBER:	198603540
ADMINISTRATOR:	MCGEE, JAMES		FACILITY TYPE:	740
ADDRESS:	1379 E. ADAMS PARK DR		TELEPHONE:	(951) 532-4644
CITY:	COVINA	STATE: CA	ZIP CODE:	91724
CAPACITY:	6	CENSUS: 0	DATE:	02/04/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Barbara Boiston, Manager		TIME COMPLETED:	01:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Tao, conducted an announced visit to the facility for purpose of a prelicensing evaluation. LPA met with Barbara Boiston, Manager, who assisted with the visit. An application was submitted to CCLD on 12/23/2021, for change of location for a Residential Care Facility for the Elderly to serve the Elderly for ages 60 years and older. The requested capacity is for six (6) including six (6) non-ambulatory and 0 bedridden. The previous licensed facility is ST ELIZABETH'S HOME FOR THE ELDERLY II, facility number 198601681. Applicant applied for dementia program. Structure: Facility is a single house with four (4) resident bedrooms, two (2) bathrooms, living room, kitchen, backyard with shaded area, and two (2) car with laundry area in the attached garage. The resident bedrooms are spacious and will easily accommodate the residents furnishings. Passageways, walkways, driveways, steps and patios are free from obstructions. Bedrooms Residents: Bedrooms are for six (6) non-ambulatory residents and in compliance. Bathrooms: All bathrooms have a working toilet, wash basin, bath-tub/shower. Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Applicant will transfer supplies from the previous location to this facility as well. ( - continued in LIC 809 C - )

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 02/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2022

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 ELIZABETHS HOME FOR THE ELDERLY	FACILITY NUMBER: 198603540
	VISIT DATE: 02/04/2022

NARRATIVE

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Emergency Phone Numbers, Exit Plan & Menu:
Posted & readily available for review at the entrance. Fire Extinguisher located at kitchen mounted on the wall.

Smoke Detectors:
Carbon monoxide detectors and smoke detectors are operational.

Appliances:
Stove burners, oven, microwave, washer, and dryer working. Auditory alarm devices are operable.

Toxins:
All cleaning compounds, poisons and toxins are stored and inaccessible to residents.

Water Temperature:
Tested at 108.5 degrees Fahrenheit and in compliance.

Medications and Resident records:
Medication cabinet and resident records cabinets are locked and available to staff but inaccessible to residents. Applicant will transfer resident records from the previous location to this facility when residents move in.

No issues were observed during the visit.

Component III:
Conducted at the Pre-Licensing visit, information provided about how to operate the facility within substantial compliance.

An exit interview was conducted and a copy of this report has been furnished to the applicant. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to their application.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 02/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2022

LIC809 (FAS) - (06/04)

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