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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005549
Report Date: 09/30/2021
Date Signed: 09/30/2021 04:04:20 PM

Document Has Been Signed on 09/30/2021 04:04 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ST. JUDE CARE HOMEFACILITY NUMBER:
306005549
ADMINISTRATOR:DAVID, FERNANFACILITY TYPE:
740
ADDRESS:1200 W. BALL RDTELEPHONE:
(657) 201-3401
CITY:ANAHEIMSTATE: CAZIP CODE:
92802
CAPACITY: 6CENSUS: DATE:
09/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Fernan David TIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Norman Woodridge conducted a Covid-19 Annual Inspection at the facility. Upon arrival, LPA informed Staff (S1) of the purpose of the visit and was granted entry into the facility. LPA met with Administrator (AD) Fernan David and discussed the purpose of the inspection. During the inspection, LPA and S1 conducted a tour of the inside and outside of the facility, common areas, resident rooms, garage, and kitchen.

LPA observed the following:

There were 2 staff and 4 residents present at the facility. Resident rooms were clean and organized. LPA observed a 2-day supply of perishables and a 7-day supply of non-perishables. LPA observed hallways and walkways that were free of obstruction. LPA and AD discussed Provider Information Notice 21-38-ASC: Update Guidance for the Use of Masks, Surgical Masks, Respirators Related to Coronavirus Disease 2019 (COVID-19). LPA also discussed Covid-19 Mitigation Plan.


No deficiencies were noted during the inspection.

An exit interview was conducted with AD and a copy of this report was provided.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Norman Woodridge
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2021
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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