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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603540
Report Date: 02/10/2023
Date Signed: 02/10/2023 11:44:53 AM


Document Has Been Signed on 02/10/2023 11:44 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
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:
02/10/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Barbara Boiston, House Manager/Assistant AdministratorTIME COMPLETED:
11:50 AM
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Licensing Program Analysts (LPA) Galarza and Tena Herrera conducted an unannounced Case Management visit to ensure the licensee is in compliance with regulation and to follow up on physical plant deficiency observed during the annual inspection conducted on 2/2/2022. The purpose of the visit was explained to Caregiver staff Robert Tuazon. A tour of the facility was conducted.

On 2/2/2023, during the annual inspection staff (S2 &S4) were observed living in the garage. The living quarters does not have a city permit or Fire Department clearance.

On 2/3/2023, House Manager submitted a written POC stating that staff (S2 & S4) have vacated the garage, and staffing schedules have changed to 12 hour shifts.

OBSERVATIONS:

  • Staff (S1 & S4's) personal belongings i.e. clothes, bed, and furniture were still observed in the garage area. Per House Manager, staff vacated the garage and are no longer sleeping at the facility. Staff (S2 & S4) are working 12 hour shifts. Ms. Boiston and caregiver Staff (S2) stated that S2 & S4 are not living at the facility, but the personal belongings have not been removed because staff are still looking for storage facilities.
  • House Manager Barbara Boiston stated Staff (S2 & S4) will be removing the personal belongings by Friday, February 17, 2023.

Deficiency "87305(a) Alterations to Existing Building or New Facilities(a) Prior to construction or alterations, all facilities shall obtain a building permit" was cleared today.

Exit interview was conducted with House Manager Barbara Boiston. A copy of the report was issued.

SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2023
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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