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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603631
Report Date: 08/07/2024
Date Signed: 08/07/2024 10:27:53 AM


Document Has Been Signed on 08/07/2024 10:27 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 ELDERLYFACILITY NUMBER:
198603631
ADMINISTRATOR:MCGEE, BRIANAFACILITY TYPE:
740
ADDRESS:3203 E CAMERON AVETELEPHONE:
(626) 331-7714
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY:6CENSUS: 4DATE:
08/07/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Briana McGee, AdministratorTIME COMPLETED:
10:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Cynthia Chan conducted a case management visit to issue a deficiency found during a complaint investigation. LPA explained the reason to administrator, Briana McGee.

During the visit, LPA measured the hot water temperature. The hot water was measured at 137.5 degrees F in the resident's common bathroom which is over the required range.

A deficiency is issued on the LIC809D and a civil penalty for a repeated violation has been assessed. An exit interview was held. A copy of this report along with appeal rights was given to the administrator.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:
DATE: 08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024
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 08/07/2024 10:27 AM - 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: 08/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/08/2024
Section Cited
CCR
87303(e)(2)

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(e) Water supplies and plumbing fixtures...(2) Faucets used by residents for personal care...shall deliver hot water. Hot water temperature controls shall be maintained ...not more than 120 degree F (49 degrees C).This requirement is not met as evidenced by:
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The licensee shall submit plan to ensure the hot water temperature is within the 105-120 degrees F and also a log in which the hot water was measured for each shift. These items shall be submitted to LPA by 8/8/24.
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Based on observation, the hot water temperature was not maintained within the required range which poses an immediate health and safety concern for residents in care.
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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: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:
DATE: 08/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024
LIC809 (FAS) - (06/04)
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