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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603898
Report Date: 05/19/2026
Date Signed: 05/19/2026 02:19:07 PM

Document Has Been Signed on 05/19/2026 02:19 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ST. JUDE'S ELDER CARE IVFACILITY NUMBER:
198603898
ADMINISTRATOR/
DIRECTOR:		RAGANO, SCOTTFACILITY TYPE:
740
ADDRESS:1324 SOUTH DONNA BETHTELEPHONE:
(909) 263-3787
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY: 6CENSUS: 6DATE:
05/19/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:23 AM
MET WITH:Jinky Rose Nagai - CaregiverTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit. LPA was
met by Jinky Rose Nagai and Alex John Banal, Caregivers and explained the purpose of the visit. At 10:45am, Tiffany Vanderpoorten, designated Administrator arrived to drop off files. The facility is approved to serve residents age range 60 and above, (1) ambulatory & (5) non ambulatory. Hospice granted for (6). LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:
Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were maintained.
Staff are trained in the proper use of all required PPEs prior to being around residents. Bathroom has hygiene
items such as paper towel, hand soap and toilet paper.
Operational Requirements: Facility has working signal systems in exit points, with the exception of the exit door in one of the resident's bedrooms, which was not functioning when tested. Facility maintains liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate and expires on 11/04/2026.
Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood which now consists of (7) bedrooms, one of which is a staff bedroom, (3) bathrooms, living room with covered fireplace, activity room with massage chairs, kitchen, dining area, laundry room and backyard with patio area. There are currently (6) residents, 60 years and older residing in the facility, (4) are under hospice care and (0) bedridden. LPA observed that the facility sketch submitted to CCLD did not match the actual lay out of the facility. LPA learned that the facility had finished construction where the garage was converted into (2) additional bedrooms and administrator failed to notify CCLD of the modification. The interior and exterior physical plant was inspected. Resident bedrooms were toured. Each bedroom has a smoke detector, linen, light, chair and sufficient closet space. The fireplace in the living room is adequately screened. Backyard was inspected and there are no swimming pool or bodies of water on the premises. There are (2) fire extinguishers in the facility which were serviced on 12/18/2025. Sufficient food supplies of 2 day perishable and at least a week of non-perishable are observed. Knives, cleaning solutions, and disinfectants are locked. Smoke alarms and carbon monoxide were tested and operable. Hot water temperature reading measured within the required 105 - 120 degrees Fahrenheit *****REPORT CONTINUED ON LIC809-C*****
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ST. JUDE'S ELDER CARE IV
FACILITY NUMBER: 198603898
VISIT DATE: 05/19/2026
NARRATIVE
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Staffing: A total of (3) caregivers including the Administrator provide care and supervision to the residents.
One (1) staff provides night supervision and can assist in caring for residents in the event of an emergency.
Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have the
required training and associated to the facility.
Personnel Records-Training: All three (3) staff files were reviewed for criminal background clearance and
training. Personnel records have health/TB screenings. Administrator has completed the required Administrator courses and certificate is valid through 09/12/2027.
Resident Rights-Information: Resident personal rights are posted. Facility provides internet services to all
residents and have access to the facility phone. Facility provides initial and ongoing training for staff.
Planned Activities: Information regarding Dementia is part of training for direct care staff and is included in
the Plan of Operation. The facility provides sufficient space to accommodate both indoor and outdoor activities.
Food Service: The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day
non-perishable food. Pesticides and cleaning supplies are kept away from the food preparation areas.
Incidental Medical Services: Residents' medications were reviewed during the visit. The facility uses the
centrally stored medication log to document medications given. Medications are stored in a locked cabinet and inaccessible to residents. However, LPA observed the cabinet to be unlocked during the inspection.
Resident Records-Incident Reports: Six (6) resident files were reviewed containing admission
agreements, Physician's Report, Medical/Functional assessments, Needs and Services Plans, TB clearance,
Personal rights, Medical Consent, Medication Records.
Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan containing
emergency evacuation, storage and preservation of medications, operation of manual assist devices. Fire drill
conducted monthly, last fire drill was on 04/01/2026.
Residents with SHN: Currently, there are no residents under hospice care.

An Immediate Civil Penalty $500 was assessed due to a Fire Clearance Violation and deficiencies cited.

Exit interview and a copy of this report along with the appeal rights were provided to Jinky Rose Nagai, Caregiver.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/19/2026 02:19 PM - It Cannot Be Edited


Created By: Bennette Pena On 05/19/2026 at 01:26 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ST. JUDE'S ELDER CARE IV
FACILITY NUMBER: 198603898

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in that one of the resident's room in the new dwelling unit from the newly constructed garage conversion does not have a fire clearance which poses an immediate health, safety or personal rights risk to residents in care.
POC Due Date: 05/20/2026
Plan of Correction
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Licensee/administrator to submit a completed STD850 and LIC 200 to CCLD by 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.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Bennette Pena
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/19/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/19/2026 02:19 PM - It Cannot Be Edited


Created By: Bennette Pena On 05/19/2026 at 01:26 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ST. JUDE'S ELDER CARE IV
FACILITY NUMBER: 198603898

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type B
Section Cited
CCR
87463(h)(1)
Reappraisals
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. (1) Documentation of the annual routine visit, such as a visit summary, shall be added to the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation. interview, record review, the licensee did not comply with the section cited above in that a resident diagnosed with dementia did not have a current medical assessment on file, last medical assessment on file was 08/02/2024 which poses/posed a potential health, safety or personal rights risk to residents in care.
POC Due Date: 05/29/2026
Plan of Correction
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Licensee/administrator to submit an updated physician's report to CCL/LPA by 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.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Bennette Pena
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/19/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2026


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 05/19/2026 02:19 PM - It Cannot Be Edited


Created By: Bennette Pena On 05/19/2026 at 01:27 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ST. JUDE'S ELDER CARE IV
FACILITY NUMBER: 198603898

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type B
Section Cited
CCR
87208(a)(7)(A)
87208 Plan of Operation
(a) The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following:
(7) Sketches, showing dimensions, of the following:
(A) Building(s) to be occupied, including a floor plan that describes the capacities of the buildings for the uses intended and a designation of the rooms to be used for nonambulatory residents and for bedridden residents, other than for a temporary illness or recovery from surgery as specified in Sections 87606(d) and (e)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in that the facility sketch on the plan of operation and submitted to CCLD did not match the actual lay out of the facility due to a recent construction of garage conversion which poses/posed a potential health, safety or personal rights risk to residents in care.
POC Due Date: 05/29/2026
Plan of Correction
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Licensee/administrator shall update the plan of operation, submit the necessary requirements such as building permits, along with the updated sketch. In addition, administrator shall submit a signed self certification acknowledging understanding of Title 22 Regs, 87208 to CCLD by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Bennette Pena
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/19/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2026


LIC809 (FAS) - (06/04)
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