198603631-5-23-2024-28-AS-NGAA-D5K2F3-20240523172054

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603631
Report Date: 05/23/2024
Date Signed: 05/23/2024 05:21:06 PM

Document Has Been Signed on 05/23/2024 05:21 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		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: 6	DATE:	05/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Briana McGee, Administrator		TIME COMPLETED:	05:25 PM

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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit. The purpose of the visit was explained to caregiver staff Feiby Angeli Estanislao. Administrator Briana McGee arrived shortly after. There are currently 6 elderly residents 60 years and older residing in the facility. The following 12 Care Compliance and Regulatory Enforcement (CARE) tool domains were utilized during the inspection.

Infection Control:

The facility has an Infection Control Plan. Supplies of Personal Protective Equipment (PPEs) were observed. A visitor sign-in sheet is in place.

Operational Requirements:

An Infection Control Plan has been added to the Plan of Operation.
The facility has a Dementia Waiver in place and an approved Hospice Waiver for 6 residents.
A fire clearance for 6 non-ambulatory residents in bedrooms #1 - #3. Bedroom #4 is for staff use only.
Liability Insurance in the amount of ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is current with an expiration date of 6/27/2024.
An American Red Cross 1st Aid kit and manual are readily available.
No Surety bond is in place. Facility does not handle resident monies.

*Narrative continues next page.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

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	FACILITY NUMBER: 198603631
	VISIT DATE: 05/23/2024

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Physical Plant/Environment Safety:

The facility is a single-story home located in a residential area consisting of four (4) bedrooms, two (2) full bathrooms, kitchen, dining room, living room, laundry room, rear shaded patio area, backyard basketball court, and detached garage. The facility has one (1) fully charged fire extinguisher. Smoke and carbon monoxide detectors are operational.
The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Cleaning supplies and toxic substances were observed in the unlocked laundry room and the cabinet underneath the kitchen sink has a locking mechanism that is easily accessible to residents in care.
Water temperature readings did not measure within the required 105 - 120 degrees Fahrenheit.
Residents (R1 & R2) had 1/2 bed rails without a physician order, and R3 had full bed rails without being enrolled in hospice.
Resident (R1's) medications were observed unlocked on top of the side dresser. Roommate has Dementia.

Staffing:

A total of four (4) staff members provide care and supervision to the clients.

Personnel Records/Staff Training:

Administrator certificate expired 11/19/2023. Recertification is pending approval.
Four (4) staff files were reviewed. Proof of staff training, health clearance, 1st Aid/CPR training, and criminal background clearance was reviewed.

Resident Records/Incident Reports:

A total of six (6)resident files were reviewed. They contained admission agreements, Physician's Reports, TB clearance, Physician's Orders, medical consent, and medication records. None of the resident files had Appraisal Needs/Services Plans, and R1-R3 did not have physician orders for bed rails.
RCFE complaint poster and Personal rights are posted.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

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	FACILITY NUMBER: 198603631
	VISIT DATE: 05/23/2024

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Planned Activities:

Sufficient space to accommodate both indoor and outdoor activities was observed. Activities are individualized.
The facility does not have a Resident Council.

Food Service:

Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies.
Three (3) residents have a physician order for a modified diet.

Incident Medical and Dental:

Three (3) centrally stored resident medications were reviewed to verify there is a 30-day supply of medications. Resident (R1) had unlocked medications in their room.
Medical and dental transportation is provided by families.

Disaster Preparedness:

An Emergency and Disaster Plan is place.
Disaster drill logs were not provided because they are off site.

Residents with Special Health Needs:

Two (2) residents are receiving hospice services. One (1) resident receives home health services.
Postural support physician orders were not observed in all resident files. Full and half bed rails for mobility assistance were observed in all resident rooms; however residents (R1-R3) need physician's orders. No residents have prohibited health conditions.
Appraisals are on file.

Per California Code of Regulations, Title 22, deficiencies were cited.

Exit interview was conducted with Briana McGee. A copy of the report and appeal rights will be emailed due to printing difficulties.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/23/2024 05:21 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
CCLD Regional Office, 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: 05/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that the hot water temperature readings were 126.7, 120.2, & 117.7 degrees Fahrenheit; which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/24/2024
	Plan of Correction
1 2 3 4	Submit a written plan of correction and a hot water temperature log that demonstrates the water was tested during each shift today and tomorrow.

Type A

Section Cited

CCR

87465(h)(2)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that Resident (R1's) medications were observed on top of the side dresser, and their roommate is ambulatory with Dementia, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/24/2024
	Plan of Correction
1 2 3 4	Submit proof of staff training and a written plan stating how the defiency was addressed.

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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/23/2024 05:21 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
CCLD Regional Office, 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: 05/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87608(a)(5)(A)

Postural Supports

(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having 1/2 rails on R1 & R2's beds without a physician's order, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/24/2024
	Plan of Correction
1 2 3 4	Submit a copy of the physician's order and/or proof that the request was sent to the physician.

Type A

Section Cited

CCR

87608(a)(5)(B)

Postural Supports

(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that resident (R3) has full bed rails without being enrolled in hospice, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/24/2024
	Plan of Correction
1 2 3 4	Administrator agreed to remove the full rails from resident (R3's) bed because they are not enrolled in hospice. Submit a copy of the 1/2 bed rail physician order.

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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/23/2024 05:21 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
CCLD Regional Office, 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: 05/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(a)(8)(A)

Incidental Medical and Dental Care Services (A) A current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by not having a first aid manual at the facillity,which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/30/2024
	Plan of Correction
1 2 3 4	Submit proof that a 1st Aid manual was purchased.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

LIC809 (FAS) - (06/04)

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