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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603344
Report Date: 10/19/2021
Date Signed: 10/19/2021 10:27:37 AM

Document Has Been Signed on 10/19/2021 10:27 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. JUDE'S ELDER CARE IIFACILITY NUMBER:
198603344
ADMINISTRATOR:RAGANO, SCOTTFACILITY TYPE:
740
ADDRESS:502 SOUTH DARWOOD AVENUETELEPHONE:
(909) 263-3787
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY: 6CENSUS: 6DATE:
10/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:01 AM
MET WITH:Judy Ragano, LicenseeTIME COMPLETED:
10:40 AM
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Licensing Program Analyst (LPA) Vasallo conducted an annual required visit. LPA met with licensee, Judy Ragano and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA observed the physical plant, COVID-19 procedures, reviewed residents' medications, observed food supply, and reviewed resident and staff files. Facility has submitted a mitigation plan and the plan has been approved.

All 4 resident bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, and sufficient closet space. Both bathrooms were toured. Bathrooms have the required grabs bars and non-skid mats. The hot water was 109 degrees which is within the required 105 - 120 degrees. The kitchen was toured. All appliances were operating properly. There was sufficient perishable food in the kitchen and garage refrigerators. There were a variety of foods including meats, vegetables, and fruit. There was sufficient non-perishable food in the pantry. The common areas including the living rooms and dining room are clean and have the required furniture. The back yard has a shaded area and sitting area.

LPA reviewed 3 resident files. Files were complete and included appraisals, physician's reports, medical consent, personal inventory forms. LPA also reviewed staff files to confirm health screenings, fingerprint clearances and training. LPA reviewed 3 residents' medications. Medications are documented properly and given as prescribed.

There was a technical advisory given to the facility for failure to assess LPA at the point of entry. This is a requirement for COVID-19 procedures. There were no deficiencies documented. A copy of the report and technical advisory were provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Tony Vasallo
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2021
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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