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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601713
Report Date: 11/07/2022
Date Signed: 11/07/2022 05:10:44 PM

Document Has Been Signed on 11/07/2022 05:10 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:
11/07/2022
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Paul Shay- LicenseeTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit at the facility to conduct the required annual inspection, using the Infection Control Evaluation tool. LPA Maldonado met with caregiver Ceferino Vicente and explained the purpose for the visit. LPA conducted a tour of the physical plant with the caregiver, observed COVID-19 procedures, food supply, reviewed residents' medications, and resident and staff files. Facility has submitted a mitigation plan and the plan has been approved.

The facility is a one-story home located in a residential area and is licensed to serve (6) residents, ages 60 and over. The license is approved for (6) non-ambulatory residents, approved hospice waiver for (6), approved for (1) bedridden resident, and an approved dementia care plan. The home consists of (5) resident bedrooms, (2) bathrooms, kitchen, dining room, living room, TV room, laundry room, a shaded patio in the backyard, (2) caregiver rooms, and an attached garage. (1) resident bedroom is shared and (4) are private. LPA observed all resident bedrooms to have the required furniture, linens, and closets with additional storage space. Additional clean linens were observed in a hallway closet and were observed to be in good condition. All entrances/exits were observed to have operating auditory devices during the visit. All walkways and pathways were observed to be free of obstructions and hazards. The food supplies in the facility was observed to be a variety of nutritious foods. The required 2-day of perishables and 7-day non-perishables foods were observed in the kitchen pantry & refrigerators in the kitchen and the garage.

At 1:25PM, all cleaning supplies/toxins were observed in a cabinet in underneath the kitchen sink, unlocked and accessible. A knife was left on the kitchen counter, unsupervised for 7 minutes, until staff returned to continue food preparations. All other sharps were observed to be stored in a kitchen drawer next to the sink, inaccessible to persons in care.


(Report Continued on LIC809-C...)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2022
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. PAUL'S HOME FOR THE ELDERLY, INC.
FACILITY NUMBER: 198601713
VISIT DATE: 11/07/2022
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LPA observed the door to the central file/medication storage to be open and accessible. The key to the medication cabinet was hanging from the door and was not locked when inspected with the caregiver. The caregiver went to move items from the floor to close and lock the door.

Several fire extinguishers were observed throughout the home to have recent inspections and be fully charged. LPA observed the bathrooms in the home to have a toilet, shower, and wash basin- all in good repair and operational. The water temperature was tested and measured at 112.3*F in bathroom#1 and 113.6*F in bathroom#2.

Smoke/carbon monoxide detectors were observed throughout the facility and were operational upon testing. The First Aid Kit was observed to have the required items and First Aid Manual.

LPA did not observe COVID-19 signange posted throughout the facility to promote mask wearing, cough/sneeze etiquette, and social distancing. A sufficient 30-day supply of Personal Protective Equipment (PPE) was observed in the garage and throughout the facility, accessible to residents, staff, and visitors. Staff failed to screen LPA upon entry to the facility for temperature and COVID-19 symptoms. Another staff and a visitor were also observed to enter the facility without being screened. Upon entry to the facility, staff were observed to not be wearing face masks until LPA asked them to put one on. All hand washing stations were observed to have sufficient soap and paper towels.

LPA reviewed 6 of 6 resident files. Files were complete with health screenings and updated emergency contact information. LPA also reviewed 3 staff files to confirm health screenings, fingerprint clearances, and required training certification. LPA reviewed 5 residents' medications. Medications are documented properly and given as prescribed.

Per California Code of Regulations and Health and Safety Codes, deficiencies were observed and will be cited on the LIC809-D report. Technical advisories were also given to the facility for failure to follow all infection control practices.

An exit interview was conducted with licensee Paul Shay and a copy of the report, technical advisories, and appeal rights were provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/07/2022 05:10 PM - It Cannot Be Edited


Created By: Valeria Maldonado On 11/07/2022 at 04:56 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. PAUL'S HOME FOR THE ELDERLY, INC.
FACILITY NUMBER: 198601713

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
87705 Care of Persons with Dementia
(f)The following shall be stored inaccessible to residents with dementia:(1)Knives...(2)toxic substances such as...cleaning supplies and disinfectants.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interviews, and records review, the licensee failed to maintain knives and toxic substances (cleaning supplies and bug killers) inaccessible to residents in care, which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
POC Due Date: 11/08/2022
Plan of Correction
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Licensee ensured the sharps and cleaning supplies/toxins were put away immediately and made inaccessible to residents in care.
Type A
Section Cited
CCR
87465(h)(2)
87465 Incidental Medical and Dental Care
(h)The following requirements shall apply to medications which are centrally stored:(2)...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.
This requirement was 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 maintaining the centrally stored medications locked and inaccessible to residents, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/08/2022
Plan of Correction
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Licensee ensured the centrally stored medications were locked immediately, Deficieny will be cleared.
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: 11/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2022


LIC809 (FAS) - (06/04)
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