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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603540
Report Date: 02/02/2023
Date Signed: 02/02/2023 12:21:34 PM


Document Has Been Signed on 02/02/2023 12:21 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 ELIZABETHS HOME FOR THE ELDERLYFACILITY NUMBER:
198603540
ADMINISTRATOR:MCGEE, JAMESFACILITY TYPE:
740
ADDRESS:1379 E. ADAMS PARK DRTELEPHONE:
(951) 532-4644
CITY:COVINASTATE: CAZIP CODE:
91724
CAPACITY:6CENSUS: 6DATE:
02/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Barbara Boiston, House Manager/Assistant AdministratorTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analysts (LPA) Galarza conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with staff Robert Tuazon and explained the purpose of the visit. House Manager Barbara Boiston arrived shortly after. There are six (6) elderly residents in the home. A Hospice Waiver for six (6) residents is in place. The facility is a single story home licensed to serve 6 residents age 60 and above; of which 6 may be non-ambulatory in rooms 1-4. It consists of 4 resident bedrooms, 2 bathrooms, dining room, kitchen, living rooms, outdoor patio, and attached garage. The last fire/emergency drill was conducted on 10/18/2023. Assistant Administrator certificate expires 9/7/2024.

OBSERVATIONS:
  • The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. Smoke and carbon monoxide detectors were tested and operational.
  • COVID-19 Infection Control Practices and signs that promote hand washing, cough/sneeze etiquette, and physical distancing were observed in the entrance, common areas, hallways, bathrooms and client rooms. There is a screening station at the entrance of the facility to screen visitors.
  • If needed room assignments would temporarily change in order to designate a COVID-19 isolation room.
  • A posted Emergency Disaster Plan was observed.
  • Centrally stored resident medication records were observed to be locked.
  • Staff were observed wearing mask. Residents were not observed wearing masks.
  • The kitchens were inspected and have sufficient supply of 2 day perishable & 7 day non-perishable food.
  • Facility has an adequate 30-day+ supply of Personal Protective Equipment (PPEs).
  • Paint cans were observed in the exterior side yard area. Staff removed and locked the hazardous items.
  • Staff associations were discussed due to Guardian issues after address and facility license change.
  • An Infection Control Plan (ICP) has been submitted. Facility must update LIC 500 Personnel Report.
***NOTE: Staff (S2 &S4) are living in the garage. Licensee does not have a city permit.
Deficiencies were cited. See LIC 809D.
Exit interview was conducted with House Manager Barbara Boiston. A copy of the report and appeal rights were issued.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2023
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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Document Has Been Signed on 02/02/2023 12:21 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 ELIZABETHS HOME FOR THE ELDERLY
FACILITY NUMBER: 198603540

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that there were many paint cans along the side wall in the exterior physical plant; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/03/2023
Plan of Correction
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Facility staff removed the paint cans during the visit. Deficiency CLEARED.
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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 02/02/2023 12:21 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 ELIZABETHS HOME FOR THE ELDERLY
FACILITY NUMBER: 198603540

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87305(a)
Alterations to Existing Building or New Facilities

Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all facilities shall obtain a building permit.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that staff (S2 & S4) live in the garage. The licensee does not have a city permit and it is not noted on the plan of operation or facility sketch; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/03/2023
Plan of Correction
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Licensee shall:
1. Contact City Planning Code Enforcement department and Fire Department regarding building permit.
2. Staff (S2 & S4) must vacate the garage by tomorrow.
3. Submit a written plan of correction and proof that the aforementioned items have been completed.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2023
LIC809 (FAS) - (06/04)
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