198603630-7-23-2025-28-AS-SVAD-DJUN4Y-20250723100843

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603630
Report Date: 07/15/2025
Date Signed: 07/23/2025 10:08:54 AM

Document Has Been Signed on 07/23/2025 10:08 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	ST. SEBASTIAN'S HOME FOR THE ELDERLY II		FACILITY NUMBER:	198603630
ADMINISTRATOR/ DIRECTOR:	MCGEE, BRIANA		FACILITY TYPE:	740
ADDRESS:	1379 E ADAMS PARK DR		TELEPHONE:	(626) 222-2641
CITY:	COVINA	STATE: CA	ZIP CODE:	91724
CAPACITY: 6		CENSUS: 5	DATE:	07/15/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:50 AM
MET WITH:	Administrator Briana Mcgee		TIME VISIT/ INSPECTION COMPLETED:	04:00 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) Vaid conducted an unannounced annual inspection visit. LPA met with Barbara Boiston, house manager. Administrator, Briana McGee, arrived shortly after to assisted with the visit. Facility is licensed to serve six (6) non-ambulatory elderly residents, ages 60 and above. No bedridden allowed. Hospice waiver approved for six (6) residents. During the visit, CARE tool was used, a tour of the facility was conducted, food supply/medication were reviewed, staff/residents were interviewed, and staff/residents’ records were reviewed. The facility is located in a residential neighborhood. The facility consisted of four (4) bedrooms approved for non-ambulatory residents, two (2) bathrooms, kitchen, dining area, laundry area, and living room with a TV. All the rooms were furnished with appropriate furniture for residents’ comfort. The bathrooms were furnished with grab bars and nonskid surfaces. Common areas were observed for the ability to safely serve the needs of the residents. Hot water temperature was 108.4- and 112.9-degrees Fahrenheit, respectively. Adequate linen and personal hygiene supplies were observed. No pools and bodies of water on the premises. Facility maintained a comfortable temperature for residents. Auditory alarm devices to monitor exits were operable. Interior and exterior space available to permit residents to wander freely and safely. Sufficient supplies of perishable and nonperishable foods were observed. Knives, tools, sharp items were inaccessible to residents. Smoke detectors and carbon monoxide detectors were operable. Fire extinguishers' last service was 4/16/25 and were fully charged. Medication, residents'/ staff records were centrally stored in a locked cabinet and inaccessible to residents. Toxic substances were inaccessible to residents. Administrators certificate expires 11/19/25. House manager Barbara Boiston certificate expires 09/06/26. No deficiencies were observed per California Code of Regulations, Title 22. An exit was presented to Briana McGee.

Fernando Fierros	TELEPHONE: (323) 981-3981
Sanjay Vaid	TELEPHONE: 916-215-7924
	DATE: 07/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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