198603630-6-16-2023-28-AS-BTAO-CSUVJU-20230616162921

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603630
Report Date: 06/16/2023
Date Signed: 06/16/2023 04:30:22 PM

Document Has Been Signed on 06/16/2023 04:30 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. SEBASTIAN'S HOME FOR THE ELDERLY II		FACILITY NUMBER:	198603630
ADMINISTRATOR:	MCGREE, BRIANA		FACILITY TYPE:	740
ADDRESS:	1379 E ADAMS PARK DR		TELEPHONE:	(626) 222-2641
CITY:	COVINA	STATE: CA	ZIP CODE:	91724
CAPACITY:	6	CENSUS: 6	DATE:	06/16/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Briana McGee, Applicant		TIME COMPLETED:	04:15 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) Tao conducted an announced pre-licensing inspection. This is a change of ownership. Applicant is applying for Residential Care for Elderly to serve residents for age 60 and above. The facility was previously licensed to St Elizabeth’s Home for the Elderly with facility# 198603540. The current applicant’s licensee is St. Sebastian Home of the Elderly, LLC. LPA met with Briana McGee, applicant/ administrator. The requested capacity is six (6). Facility has an approved Dementia Care Plan. Hospice waiver was approved for six (6). Administrator certificate is current with expiration date on 11/19/23. Fire clearance: Fire clearance was granted on 03/20/23 for six (6) non-ambulatory and zero (0) bedridden. Fire clearance and Dementia care plan are in place. Auditory device is installed at all exits and operable. Structure: The property is a single-family residence located in a neighborhood, consisting of four (4) bedrooms approved for non-ambulatory residents, two (2) bathrooms, kitchen, dining area, laundry area, and living room with a TV. Passageways, walkways and patios are free from obstructions. The entrance and side areas are free of hazards and debris. Signal system and Garage: Facility does not have a signal system. Garage is not accessible to residents. (- Continued 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: 06/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023

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. SEBASTIAN'S HOME FOR THE ELDERLY II	FACILITY NUMBER: 198603630
	VISIT DATE: 06/16/2023

NARRATIVE

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Bedrooms for Residents:
Bedrooms have night stands, adequate lighting, adequate closet and drawer space. Bedrooms are spacious and allow for easy passage between and comfortable for usage.

Bathrooms:
Toilet, wash basin, bathtub/shower in bathrooms are operable. Bedrooms are accommodated for residents. Grab bars are maintained for each toilet, bathtub and shower.

Linens & Hygiene Supplies:
Sufficient linen/supplies which include pillowcases, mattress pads, blanket and bedspreads are available. Adequate supply of linen, wash clothes and towels are observed.

Food Service:
Dishes, cups and flat ware are stored in the kitchen cupboards, inspected and in good repair. Dishwasher in kitchen properly installed and functioning. Knives, cutlery and other sharp kitchen utensils are stored in a locked cabinet in the kitchen and inaccessible to residents. Food supply consist of two days of perishable and two weeks of non-perishable was observed.

Medications, First-Aid Kit & Book:
Medication cabinet is installed with a lock and inaccessible to residents. First aid kit has a thermometer, tweezers, scissors, antiseptic, bandages, and gauze. First Aid manual from American red cross was available for staff use and inaccessible to residents.

Smoke Detectors:
Dual Smoke /carbon monoxide detectors are tested and operable. They are located in hallways and each bedroom.
(-Continued 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: 06/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023

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. SEBASTIAN'S HOME FOR THE ELDERLY II	FACILITY NUMBER: 198603630
	VISIT DATE: 06/16/2023

NARRATIVE

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Appliances:
Stove burners, oven, microwave, washer, and dryer working. The refrigerator is located in the kitchen which measured temperature of at least 45 degrees Fahrenheit for appropriate food storage. Freezer is at (0) zero degrees Fahrenheit. The residence is equipped with central air and heat.

Toxins:
Poisons, toxins, and cleaning supplies are locked and inaccessible to residents. They are stored separately from food source.

Emergency Phone Numbers, Exit Plan, Signages and posters:
Emergency Disaster Plan and Labor law poster are posted. Exit Plan are available for review.

Outdoor activity area in backyard:
Outdoor activity area is furnished with chairs and table and in compliance. Shaded area in the backyard at the outdoor activity area is provided.

Residents & Staff Files:
Locked cabinets for records of staff and residents are installed and available. Residents file are observed. Applicant will not handle cash resources for residents.

Water Temperature:
Tested at 114.0 degrees Fahrenheit.

Menu and phone:
Menus are available for review. Free landline telephone is available for residents’ use and operable.
(- Continued 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: 06/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

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. SEBASTIAN'S HOME FOR THE ELDERLY II	FACILITY NUMBER: 198603630
	VISIT DATE: 06/16/2023

NARRATIVE

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Fire extinguishers:
Fire extinguisher is located at the kitchen mounted on wall. It is fully charged, and last service was done in 1/3/23.

Reading Material, Games, Equipment & Materials:
The facility has recreational materials for the residents’ use and commensurate with the plan of operation.

Pool:
No bodies of water located at the facility.

Finding:
No issue was observed during today’s visit.

Exit:
Exit conference and Component III orientation were conducted during this visit.

A copy of this report was provided to applicant. LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, s/he has been instructed to communicate with the CAB Analyst who assigned to his/her application.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023

LIC809 (FAS) - (06/04)

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