306005549-9-8-2022-22-AS-ETAA-CJ3UL7-20220908154016

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005549
Report Date: 09/08/2022
Date Signed: 09/08/2022 03:42:36 PM

Document Has Been Signed on 09/08/2022 03:42 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 HOME		FACILITY NUMBER:	306005549
ADMINISTRATOR:	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:	09/08/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Arnol Fernando		TIME COMPLETED:	04:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Edward Tapia made an unannounced required annual inspection at this facility. LPA met with staff Arnol Fernando, Richard Fernando and stated the purpose of this visit. Administrator David Fernando arrived during the inspection and provided assistance. The facility is a single-level structure licensed for six non-ambulatory with a hospice waiver for three. This facility offers Residential Care for the Elderly/Dementia. At about 1:00 pm, LPA Tapia was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. LPA Tapia reviewed the Facility Personnel Report and noticed Richard Fernando was not associated to the facility. LPA Tapia made Administrator aware of citation along with Civil Penalty. For this visit, LPA observed 5 residents in care and 2 staff members on duty. LPA toured the interior and exterior portions of the facility. There were 3 resident rooms 2 of them were shared rooms and 1 was a private room. The facility also had a staff room which is inaccessible to residents. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Bathroom (1) was observed to be in good repair and provided with grab bars and hot water was measured at 105.4 degrees Fahrenheit. LPA noticed razor blades unlocked in the bathroom. Administrator immediately removed and locked them. For the exterior portion, furniture was in good repair; and grounds were free of tripping hazards. LPA noticed shade umbrella needs to be replace due to having holes. LPA also noticed chemical spray in the backyard unlocked along with the backyard gate locked. Administrator was made aware removed chemical spray from residents in care. Administrator will also replace the lock for the gate. Facility offers a 2-car garage which is used for storage and an operational washer and dryer. Kitchen was in good repair with sharps and cleaning supplies kept locked. LPA noticed medication door did not have a lock. Administrator was made aware of this issue and will purchase a lock for the medications.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 HOME	FACILITY NUMBER: 306005549
	VISIT DATE: 09/08/2022

NARRATIVE

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LPA Tapia viewed the COVID 19 mitigation plan and the Emergency disaster plan of the facility. LPA discussed Assembly Bill 665 that requires a licensee of any adult care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

For this visit, two deficiencies were noted in areas observed along with a Civil Penalty. Three advisories were issued today.

LPA Tapia conducted an exit interview with Administrator David Fernando and copy of this report along with appeal rights were explained and left at the facility.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/08/2022 03:42 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ST. JUDE CARE HOME	FACILITY NUMBER: 306005549
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(2)

This requirement is not met as evidenced by: The following requirements shall apply to medications which are centrally stored: Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in one out of one which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/09/2022
	Plan of Correction
1 2 3 4	Administrator will purchase a lock for centrally stored medication.

Section Cited


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

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: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022

LIC809 (FAS) - (06/04)

Page: 3 of 7

Document Has Been Signed on 09/08/2022 03:42 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ST. JUDE CARE HOME	FACILITY NUMBER: 306005549
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87411(g)(2)

This requirement is not met as evidenced by: Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: Request a transfer of a criminal record clearance
	Deficient Practice Statement
1 2 3 4	This requirement is not met as evidenced by: Based on observation and record review, the licensee did not comply with the section cited above in one out of two persons which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/09/2022
	Plan of Correction
1 2 3 4	Administrator will associate individual to the facility by 09/09/2022.

Section Cited


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

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: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022

LIC809 (FAS) - (06/04)

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