<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603631
Report Date: 07/07/2023
Date Signed: 07/07/2023 01:42:50 PM


Document Has Been Signed on 07/07/2023 01:42 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:ST. SEBASTIAN'S HOME FOR THE ELDERLYFACILITY NUMBER:
198603631
ADMINISTRATOR:MCGEE, BRIANAFACILITY TYPE:
740
ADDRESS:3203 E CAMERON AVETELEPHONE:
(626) 222-2641
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY:6CENSUS: 5DATE:
07/07/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:37 PM
MET WITH:Briana McGeeTIME COMPLETED:
01:30 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 a case management visit as a result of a file review conducted in relation to complaint #28-AS-20230630104521

While LPA reviewed R1's file and observed R1's file did not have a complete record. There's only LIC603 Preplacement Appraisal Information in the resident's file. In addition, LPA asked administrator about R1's fall incident and incontinence incident on June 20th and 28th, 2023, if the facility sent any unusual incident report to Licensing. Administrator said she did but LPA reviewed the CCL internal incident reports and nothing was in the system.

The following deficiencies are noted under the California Code of Regulations Title 22 Division 6 on LIC 809D

Exit interview conducted, copy of the report and appeal rights were given.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 07/07/2023 01:42 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/14/2023
Section Cited
CCR
87506(a)(b)(1)-(17)

1
2
3
4
5
6
7
87506 Resident Records. (a)A separate, complete, and current record shall be maintained for each resident in the facility, readily available to facility staff and to licensing agency staff and shall contained specified information. (b)Each resident’s record shall contain at least the following information:
1
2
3
4
5
6
7
Administrator to submit written Plan of Correction to ensure the facility is meeting Title 22 Regulation. Licensee to submit a faxed or mailed copy of POC by due date.
8
9
10
11
12
13
14
The requirement was not met as evidenced by record reviewed, LPA only observed LIC603 in resident's files which posted a potential risk of residents in care.
8
9
10
11
12
13
14
Type B
07/14/2023
Section Cited
CCR87211(a)(1)(D)

1
2
3
4
5
6
7
87211 Reporting Requirements (a)(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1)A written report shall be submitted to the licensingThis report shall include the resident's nam.....e, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.
1
2
3
4
5
6
7
Administrator to submit written Plan of Correction to ensure the facility is meeting Title 22 Regulation. Licensee to submit a faxed or mailed copy of POC by due date.
8
9
10
11
12
13
14
(D)Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. The requirement was not met as evidenced by record review, LPA did not receive any incident reports from facility
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2