198601631-3-17-2026-28-AS-BGOZ-DS9VJ3-20260317162805

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601631
Report Date: 03/17/2026
Date Signed: 03/17/2026 04:28:16 PM

Document Has Been Signed on 03/17/2026 04:28 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 III		FACILITY NUMBER:	198601631
ADMINISTRATOR/ DIRECTOR:	JUDY RAGANO		FACILITY TYPE:	740
ADDRESS:	146 SHIRE COURT		TELEPHONE:	(909) 263-3787
CITY:	SAN DIMAS	STATE: CA	ZIP CODE:	91773
CAPACITY: 6		CENSUS: 5	DATE:	03/17/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:37 PM
MET WITH:	Administrator Judy Ragano		TIME VISIT/ INSPECTION COMPLETED:	04:35 PM

NARRATIVE

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Licensing Program Analyst (LPA) Blanca Gonzalez conducted an unannounced required annual inspection visit. LPA was greeted by staff and explained the purpose of the visit.

The facility is licensed to serve six (6) residents age range 60 and over of which five (5) can be non-ambulatory and one (1) bedridden. Hospice waiver in place for six (6) residents. There are currently five (5) residents in care, of which two (2) are receiving hospice services and one (1) resident is bedridden. The facility in operating within the limitations of there license.

The facility is a single-story home located in a residential area of San Dimas. The home consists of a living room, kitchen, dining area, family room, four (4) resident bedrooms, two (2) bathrooms, attached garage with laundry, front and back yards.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tool for the today’s visit and observed the following:

Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPA Gonzalez observed combination carbon monoxide/smoke detectors in hallways. Four (4) resident rooms were observed to contain required furniture, linens and lighting, all in good repair. LPA observed grab bars near toilets and inside shower as well as no-slip coating on shower floors. Passageways and exits are clear of obstructions. Continued on LIC809C

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Blanca Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/17/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2026

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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Document Has Been Signed on 03/17/2026 04:28 PM - It Cannot Be Edited

Created By: Blanca Gonzalez On 03/17/2026 at 03:25 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 III	FACILITY NUMBER: 198601631
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/17/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(a)(4)

Incidental Medical and Dental Care Services

(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in that morning medications (Quetiapine Fumarate) was not dispensed for R1 on March 17, 2026 which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/31/2026
	Plan of Correction
1 2 3 4	Licensee will conduct a staff training regarding assisting residents with self-administered medications and submit a training log listing topics covered and list of staff in attendence to LPA via email by POC due date.

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.

	Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:

	Blanca Gonzalez
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/17/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2026

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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ST. JUDE'S ELDER CARE III	FACILITY NUMBER: 198601631
	VISIT DATE: 03/17/2026

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Food Service: LPA observed sufficient supply of non-perishables for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and operable at time of visit.

Planned Activities: LPA observed magazines, and other activities for residents. At the time of visit, the staff and residents were celebrating St. Patrick’s Day.

Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. Emergency drills are conducted quarterly, last drill was conducted 03/03/26.

Residents with Special Needs: No pools or large bodies of water were observed. Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Auditory devices were observed to be in working order.

Health Related Services/Incidental Medical Services: Centrally stored medication are secured in a locked kitchen cabinet. LPA observed Centrally Stored Medication and Destruction Record. LPA observed morning medications were not dispensed for R1 for March 17, 2026. Deficiency cited for missed medication.

Personnel Records Training: LPA reviewed three (3) staff files and observed required annual training, CPR and First Aid for two (2) out of the three (3) personnel records reviewed, Health screening with TB testing results, fingerprint clearance and job applications.

Resident Records/Incident Reports: LPA reviewed resident records for five (5) residents in care. Resident records are maintained at the facility and contained required documentation.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during today’s visit are documented on the LIC809D.

Exit interview held and a copy of this report along with appeal rights were provided to Caregiver Maria “Josie” Alberto

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Blanca Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/17/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2026

LIC809 (FAS) - (06/04)

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