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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603672
Report Date: 12/26/2023
Date Signed: 12/26/2023 03:39:19 PM


Document Has Been Signed on 12/26/2023 03:39 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. CHRISTOPHER AND JUDE HOME FOR THE ELDERLYFACILITY NUMBER:
198603672
ADMINISTRATOR:CORSENTINO, ANTOINETTEFACILITY TYPE:
740
ADDRESS:1506 S. CANDISH AVENUETELEPHONE:
(626) 335-0429
CITY:GLENDORASTATE: CAZIP CODE:
91740
CAPACITY:6CENSUS: 6DATE:
12/26/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Barbara Boiston- AdministratorTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit at the facility for the purpose of conducting the required Post-Licensing inspection, using the Compliance and Regulatory Enforcement (CARE) Tool, to evaluate the facility. LPA Maldonado met with Administrator, Barbara Boiston, and explained the purpose for the visit.
During today's visit, LPA Maldonado conducted a tour of the physical plant with Administrator, observed the facility food supplies, reviewed (6) resident medications, (6) resident files, (3) staff files, and conducted interviews with (3) staff, and attempted interviews with (6) residents. The facility is a single-story home, operating as a Residential Care Facility for the Elderly. It is licensed to serve (6) older adults, ages 60 and over. There is a fire clearance approved for (6) non-ambulatory residents. It has an approved Dementia Care Plan and a Hospice Waiver approved for (6) residents. There are currently (3) resident receiving hospice services. An Infection Control plan has been submitted to the department for review. The facility has an active and current liability insurance policy on file.
LPA observed all resident bedrooms to have the required furniture, sufficient lighting, and closet/storage space. There are (2) full bathrooms in the home- both equipped with required grab bars and non-skid mats. The hot water was tested and measured at 107*F, which is in compliance. Food supplies was observed and was sufficient as required. Emergency food supplies and water were available. A pool was observed in the backyard- fenced and inaccessible to residents in care. Fire extinguishers were observed throughout, with current inspections and were fully charged. All sharps and cleaning supplies/toxins were observed to be locked and inaccessible to residents. Smoke/carbon monoxide detectors were observed in each room- tested and operational during today's visit. Auditory devices were observed at all entrances/exits of the home and operational. (6) resident files and (3) staff files were reviewed and observed to be complete with all required documentation. At 2:15PM, LPA reviewed (6) resident medications, and discovered (1) pill, outside of it's casing, dropped inside a drawer behind a box of gloves, where pre-punched medications were stored. Staff and administrator reviewed medication while LPA observed. It was determined that (1) medication for (1) of (6) residents was missing, as it was supposed to be administered in (2) pills at a time- this medication was administered and documented incorrectly.
Per California Code of Regulations, Title 22, citations will be cited on the LIC809-D page.
An exit interview was conducted and a copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:
DATE: 12/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/26/2023
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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Document Has Been Signed on 12/26/2023 03:39 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. CHRISTOPHER AND JUDE HOME FOR THE ELDERLY
FACILITY NUMBER: 198603672

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(c)(2)
87465 Incidental Medical and Dental Care
(c)…staff designated by the licensee shall be permitted to assist the resident with self-administration…: (2)Once ordered by the physician the medication is given according to the physician's directions.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in (1) of (6) resident's medication observed to be dropped in a drawer and determined to not have been administered as prescribed, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2024
Plan of Correction
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Administrator agreed to have In-service medication training for all staff. Sign-in sheet and training material will be emailed to LPA by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:
DATE: 12/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/26/2023
LIC809 (FAS) - (06/04)
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