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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603632
Report Date: 06/06/2024
Date Signed: 06/06/2024 05:15:07 PM


Document Has Been Signed on 06/06/2024 05:15 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 IIIFACILITY NUMBER:
198603632
ADMINISTRATOR:MCGEE, BRIANAFACILITY TYPE:
740
ADDRESS:837 N. SUNFLOWER AVENUETELEPHONE:
(626) 222-2641
CITY:COVINASTATE: CAZIP CODE:
91724
CAPACITY:6CENSUS: 5DATE:
06/06/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Briana McGee, administratorTIME COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced post licensing inspection visit. LPA met with Administrator, Briana McGee, who 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 was located in a residential neighborhood. The facility consisted of four (4) bedrooms, two (2) bedrooms were shared and two (2) bedrooms were private, two (2) bathrooms, kitchen, dining room, laundry room, garage, 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 105.3 degrees Fahrenheit. 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. 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 4/4/24 and were fully charged. Medication, residents’/ staff’s records were centrally stored in a locked cabinet and inaccessible to residents. Toxic substances were inaccessible to residents.

No deficiencies were observed and cited per California Code of Regulations, Title 22. An exit interview was conducted. This report was discussed and provided to Administrator, Briana McGee.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2024
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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