<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601713
Report Date: 04/20/2022
Date Signed: 04/20/2022 04:52:45 PM

Document Has Been Signed on 04/20/2022 04:52 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ST. PAUL'S HOME FOR THE ELDERLY, INC.FACILITY NUMBER:
198601713
ADMINISTRATOR:PAUL SHAYFACILITY TYPE:
740
ADDRESS:1311 S. GLENCROFT RD.TELEPHONE:
(626) 857-3571
CITY:GLENDORASTATE: CAZIP CODE:
91741
CAPACITY: 6CENSUS: 6DATE:
04/20/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator Paul ShayTIME COMPLETED:
03:45 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 Analysts (LPA's) Jose Villalobos and Valeria Maldonado conducted an unannounced case management visit at the facility and met with staff Jade Robles. The purpose of todays visit is to conduct a health and safety inspection. Administrator Paul Shay arrived shortly after.

During the visit LPA's toured the physical plant. LPA observed the food supply, observed locked sharps and medications. No obstructions observed. There were no signs of facility in disrepair. LPA's did not conduct any interviews at the time of the visit.

No immediate Health and Safety concerns were observed on todays visit. No deficiencies cited.

Exit interview conducted and a copy of this report was provided to Administrator Paul Shay.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 04/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/20/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1