198603631-5-24-2023-28-AS-CWOG-CS5LKV-20230524085007

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603631
Report Date: 05/23/2023
Date Signed: 05/24/2023 08:51:59 AM

Document Has Been Signed on 05/24/2023 08:51 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	ST. SEBASTIAN'S HOME FOR THE ELDERLY		FACILITY NUMBER:	198603631
ADMINISTRATOR:	MCGEE, BRIANA		FACILITY TYPE:	740
ADDRESS:	3203 E CAMERON AVE		TELEPHONE:	(626) 222-2641
CITY:	WEST COVINA	STATE: CA	ZIP CODE:	91791
CAPACITY:	6	CENSUS: 5	DATE:	05/23/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Briana McGee		TIME COMPLETED:	04:45 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), Christine Wong, conducted an announced visit to the facility for purpose of a Pre-licensing evaluation. LPA met with the administrator Briana McGee and assisted with the visit. An application was submitted to CCLD on 11/15/2022 for Change of Ownership for a Residential Care Facility for the Elderly to serve the Elderly for age range 60 and over. The requested capacity is for 6 and its approved for six (6) ambulatory residents in Bedroom#1 through #3. Bedroom #4 is for staff use only. On today's visit: LPA is using the Compliance And Regulatory Enforcement (CARE) tools to conduct the pre-licensing: 1. Physical Plant and Environment Safety: The facility is a single story house and located in a neighborhood area. The facility consists of living room, three residents bedrooms, one resident bathroom, dining area, kitchen, laundry room, live in staff room and bathroom and a detached garage. The hot water temperature in the resident bathroom is tested at 106.1 degrees F which is within Title 22 regulation. The resident bathroom is clean, sanitize and in a operable condition. The bathroom also has required grab bar and skid mat. Each resident room has two beds, two night stands, two chairs, drawers and required lighting and sufficient closet space. The linen closet is located at the hallway cabinet. The facility has ample supply of resident personal hygiene products. The facility also has a telephone service on the premises. All the sharp knives and utensils are locked in the kitchen drawer. All the cleaning supplies and chemicals are locked in cabinet in the laundry room which are inaccessible to residents. The Carbon monoxide detector is mounted on the hallway and is operational. The outdoor and passage way are free of obstruction. 2. Operational Requirements: The facility fire clearance was approved on 01/03/2023 with 6 non-ambulatory residents. 3. Staffing: The administrator is over 21 years of age. (See LIC 809C for continuation)

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ST. SEBASTIAN'S HOME FOR THE ELDERLY	FACILITY NUMBER: 198603631
	VISIT DATE: 05/23/2023

NARRATIVE

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4. Personnel Record/Staff Training: All staff files are maintained in the facility and is located and locked in the kitchen cabinet.

5. Resident Records/Incident Reports: All residents files are maintained in the facility and are located and locked in the kitchen cabinet.

6. Resident-Right Information: The facility has posted near the kitchen area but the facility does not have the resident personal right post, non-discrimination notice and Long Term Care Ombudsmen

7. Food Service: The facility has the food supply with a minium two days perishable and seven days non-perishable. All the food are stored properly to avoid cross contamination and the refrigerator temperature is within the required temperature.

8. Residents with Special Health Needs: The facility is not approved for bedridden residents. The facility has an alarm system but no delayed egress or signal system.

9. Planned Activities: The facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability.

10. Incidental Medical and Dental: The facility has a first aid kit with updated first aid manual in the facility which included all required items. All the resident medication are stored and locked in the kitchen cabinet.

11. Disaster Preparedness: The facility has an updated Emergency Disaster Plan (LIC610E) and its dated on 01/18/2023 and the facility has at least two temporary shelter alternative location.

Component III: Conducted at the Pre-Licensing visit, information provided about how to operate the facility within substantial compliance.

(See LIC 809C for continuation)

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ST. SEBASTIAN'S HOME FOR THE ELDERLY	FACILITY NUMBER: 198603631
	VISIT DATE: 05/23/2023

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During the prelicensing inspection certain items were observed which do not comply with applicable laws and regulations; the following items must be corrected and proof of correction shall be submitted to the CCLD office to the attention of LPA by 05/30/2023. If additional time is required to complete noted items to correct, then the applicant will request an extension in writing prior to the due date. Some items may require a follow up inspection for verification of correction.

1. The posted include non-discrimination notice, resident's personal right and Long Term Care Ombudsmen Poster need to be posted in the facility.

An exit interview was conducted and a copy of this report has been furnished to the applicant. Accordingly, 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, they have been instructed to communicate with the CAB Analyst assigned to their application.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

LIC809 (FAS) - (06/04)

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