Community Care Licensing

Document Has Been Signed on 09/23/2024 05:35 PM - It Cannot Be Edited

FACILITY NAME:	ST. JUDE CARE HOME		FACILITY NUMBER:	306005549
ADMINISTRATOR/ DIRECTOR:	DAVID, FERNAN		FACILITY TYPE:	740
ADDRESS:	1200 W. BALL RD		TELEPHONE:	(657) 201-3401
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92802
CAPACITY: 6		CENSUS: 5	DATE:	09/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:45 PM
MET WITH:	Fernan David		TIME VISIT/ INSPECTION COMPLETED:	05:45 PM

SUPERVISORS NAME: Sheila Santos LICENSING EVALUATOR NAME: Joseph Alejandre LICENSING EVALUATOR SIGNATURE: DATE: 09/23/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2024

Link to Parent Document Below:

FACILITY NAME: ST. JUDE CARE HOME	FACILITY NUMBER: 306005549
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/23/2024

Type A

Section Cited

HSC

1569.625(b)(2)

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 4 out of 4 staff members, none of the staff files reviewed (4) had any documented training which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/24/2024
	Plan of Correction
1 2 3 4	Licensee agrees to have the 4 staff members trained in compliance with the regulation above. Licensee agrees to forward proof of training to the LPA.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Sheila Santos LICENSING EVALUATOR NAME: Joseph Alejandre LICENSING EVALUATOR SIGNATURE: DATE: 09/23/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2024

Link to Parent Document Below:

FACILITY NAME: ST. JUDE CARE HOME	FACILITY NUMBER: 306005549
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/23/2024

Type B

Section Cited

CCR

87303(a)

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, LPA observed a hole in the wall in resident room 3 and the floor was missing tiles under the bed which poses a potential health and safety risk to persons in care.
	POC Due Date: 10/14/2024
	Plan of Correction
1 2 3 4	Licensee agrees to have the hole in the wall and the missing tiles replaced in resident room number 3 by the POC due date.

Type B

Section Cited

CCR

87463(c)

(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 4 out of 4 residents, none of the residents files reviewed (4) had a current reappraisal which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/14/2024
	Plan of Correction
1 2 3 4	Licensee agrees to complete a reappraisal for each of the 4 residents and to submit proof of correction to the LPA.

SUPERVISOR'S NAME: Sheila Santos LICENSING EVALUATOR NAME: Joseph Alejandre LICENSING EVALUATOR SIGNATURE: DATE: 09/23/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2024

Link to Parent Document Below:

FACILITY NAME: ST. JUDE CARE HOME	FACILITY NUMBER: 306005549
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/23/2024

Type B

Section Cited

HSC

1569.695(c)

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above, there is no documentation to verify there was an emergency drill conducted in the last 3 months which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/07/2024
	Plan of Correction
1 2 3 4	Licensee agrees to conduct an emergency drill in compliance with the regulation above and to send documentation of the drill to the LPA by the POC due date.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Sheila Santos LICENSING EVALUATOR NAME: Joseph Alejandre LICENSING EVALUATOR SIGNATURE: DATE: 09/23/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2024