198603540-5-11-2023-28-AS-BTAO-CRR2FU-20230511172207

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603540
Report Date: 05/11/2023
Date Signed: 05/11/2023 05:23:43 PM

Document Has Been Signed on 05/11/2023 05:23 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 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: 6	DATE:	05/11/2023
TYPE OF VISIT:	Office	UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Licensee, James McGee and applicant, Briana McGee		TIME COMPLETED:	05:15 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) Bonnie Tao and Licensing Program Manager (LPM) Fernando Fierros conducted an office meeting with Licensee James McGee and applicant Briana McGee. The purpose of the office meeting is to discuss the change of ownership and application process. Licensee is AJP INVESTMENTS, INC. The following items were discussed during today’s meeting: · Facility currently has six (6) residents of which two (2) are on hospice care · Licensee confirmed there have been no changes in the corporation · Licensee’s licensing fee are current. · Licensee will obtain an updated Control of Property - lease listing the corporation’s name and expiration date. · Licensee was informed to maintain control of property until new license is issued to applicant · Licensee confirmed there is no construction, remodeling or repairs currently needed at the facility. · Licensee reported all residents will remain at the facility and do not want to relocate. · Applicant submitted LIC 200 Application on 11/15/22. Component 1 and 2 Orientation have been completed · Applicant was informed that Component III Orientation will be scheduled by Licensing at a later time · Applicant reported fire clearance has been granted by the fire authority and the physical plant is cleared by the department. CAB is in the process of issuance of the new license. Continued on 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: 05/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2023

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 ELIZABETHS HOME FOR THE ELDERLY	FACILITY NUMBER: 198603540
	VISIT DATE: 05/11/2023

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The following were discussed and copies were provided to Licensee James:
· SB781 Leno Eviction Procedures
· AB949 Krekorian Resident Transfers
· Section 87224 Eviction Procedures
· Section 87648 Personal Rights
· Section 87468.1 Personal Rights of Residents in All Facilities
· Section 87468.2 Additional Personal Rights of Residents In Privately Operated Facilities

Licensee to submit a copy of the letter to residents regarding the Change of Ownership and a copy of the updated lease by 05/19/23.

Exit Interview conducted and a copy of this report was provided to Licensee James McGee.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2023

LIC809 (FAS) - (06/04)

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