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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204519
Report Date: 12/05/2022
Date Signed: 12/05/2022 11:53:47 AM

Document Has Been Signed on 12/05/2022 11:53 AM - 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. ANTHONY & JUDES HOMES FOR THE ELDERLY INC.FACILITY NUMBER:
198204519
ADMINISTRATOR:TERRY B. MCGEEFACILITY TYPE:
740
ADDRESS:1240 KIRKWALLTELEPHONE:
(909) 936-5424
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY: 6CENSUS: 6DATE:
12/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Nina Corsentino- Administrator TIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) V. Maldonado conducted an annual required visit. LPA met with caregiver, Ben Garcia and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA inspected the physical plant, observed food supply, COVID-19 procedures, reviewed resident and staff files, and residents' medications. Facility has submitted a mitigation plan and the plan has been approved. Administrator Nina Corsentino arrived shortly and assisted with the visit.

The home consists of 3 shared resident bedrooms, 3 bathrooms, a kitchen, dining room, living room, TV room, a shaded patio in the backyard with seating, and All resident bedrooms were toured. Each bedroom has a smoke detector, required furniture, bed linens, and sufficient closet space. LPA observed 2 of 6 resident beds to have bed rails. After review of their files, it was noted that the residents did not have a physician's order for the bed rails. All resident bathrooms were toured and have a shower, toilet, wash basin- all operational during the visit. Bathrooms have the required grabs bars and non-skid mats. The hot water was tested and measured between 110*F, which is in compliance of Title 22 Regulations. The kitchen was toured. All appliances were observed to be operating properly. There was a sufficient amount of 2-day perishable and 7-day non-perishable food. The common areas including the living room and dining room are clean and have the required furniture. There is a carbon monoxide detector in the living room. The facility has auditory devices at all doors in the facility and were observed to be operating during the the visit. Fire extinguishers were observed throughout the facility and observed to have recent inspections and were fully charged.

LPA reviewed all resident files and discovered 1 of 4 residents with dementia to not have an updated physician's report or appraisal. LPA reviewed staff files and observed them to be complete including but not limited to first aid certificates, health screenings, proof of training, and proof of fingerprint clearance.

(Report continued on LIC809-C...)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2022
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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ST. ANTHONY & JUDES HOMES FOR THE ELDERLY INC.
FACILITY NUMBER: 198204519
VISIT DATE: 12/05/2022
NARRATIVE
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 LPA reviewed all residents' medications and were observed to be documented properly and given as prescribed.

LPA observed the facility to have one central entry point for temperature check and COVID-19 symptom screening of visitors, staff, and residents. Sufficient Personal Protective Equipment (PPE) for 30 days was observed at the entrance of the facility and in the garage. All staff in the facility were observed to be wearing proper PPE at all times. Hand washing stations were observed to be fully stocked with liquid soap and paper towels. COVID-19 signage was not observed throughout the facility to promote social distancing and cough/sneeze etiquette. A technical advisory was issued as is a current requirement for COVID-19.

Per California Code of Regulations, Title 22, deficiencies were observed and will be cited on the LIC809-D.

An exit interview was conducted with Mina Coresntino and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 12/05/2022 11:53 AM - It Cannot Be Edited


Created By: Valeria Maldonado On 12/05/2022 at 11:51 AM
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. ANTHONY & JUDES HOMES FOR THE ELDERLY INC.
FACILITY NUMBER: 198204519

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

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 [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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2
3
4
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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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:Fernando Fierros
LICENSING EVALUATOR NAME:Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2022


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 12/05/2022 11:53 AM - It Cannot Be Edited


Created By: Valeria Maldonado On 12/05/2022 at 11:51 AM
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. ANTHONY & JUDES HOMES FOR THE ELDERLY INC.
FACILITY NUMBER: 198204519

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

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 [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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4
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

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 [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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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:Fernando Fierros
LICENSING EVALUATOR NAME:Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2022


LIC809 (FAS) - (06/04)
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