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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603344
Report Date: 08/13/2024
Date Signed: 08/14/2024 08:21:40 AM

Document Has Been Signed on 08/14/2024 08:21 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ST. JUDE'S ELDER CARE IIFACILITY NUMBER:
198603344
ADMINISTRATOR/
DIRECTOR:		RAGANO, SCOTTFACILITY TYPE:
740
ADDRESS:502 SOUTH DARWOOD AVENUETELEPHONE:
(909) 263-3787
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY: 6CENSUS: 5DATE:
08/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:07 AM
MET WITH:Caregiver Sheredan FabreroTIME VISIT/
INSPECTION COMPLETED:
11:10 AM
NARRATIVE
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Licensing Program Analyst (LPA) Christian Gutierrez conducted an unannounced Annual Required Visit at 8:00 AM. LPA was met by Caregiver Melinda Nofuente and explained the purpose of the visit. Administrator Judith Ragano arrived shortly. Facility is licensed to serve residents over 60 years and over. Approved for five (5) non-ambulatory, and one (1) bedridden resident.

The facility is located in a residential area. The home consists of (4) resident bedrooms, (2) bathrooms, kitchen, dining room, living room, visitor/office room, laundry room, a shaded patio in the backyard, and an attached garage.

LPA toured the facility and observed the following: Each client bedroom has the required furniture and bedding. There is extra clean linen and towels in a hallway closet. Smoke detectors were observed in each room and throughout the facility and are properly operating. There is 1 carbon monoxide in the hallway and is properly operating. The facility has one (1) fully charged fire extinguishers which is kept in the laundry room. At 8:17 AM LPA observed a bottle of Comet cleaner accessible to clients in bathroom #1 under sink. Caregiver removed and locked comet cleaner with other cleaning supplies in laundry room. Freezers are maintained at a temperature of 0-degree F and the refrigerators at a maximum of 40 degrees F. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. Sharps are locked and placed in cabinet in kitchen. There are no firearms or weapons stored at the facility. The hot water temperature in the bathrooms were measured between 96.2-116 not in the required range of 105-120 degrees F. The facility does not have a swimming pool or bodies of water on the premises There is a shaded seating area for the residents located in the backyard. Passageways and exits are free of obstruction. The garage is clean and has extra supplies.

SEE LIC 809C

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/13/2024
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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Document Has Been Signed on 08/14/2024 08:21 AM - It Cannot Be Edited


Created By: Christian Gutierrez On 08/13/2024 at 10:12 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. JUDE'S ELDER CARE II
FACILITY NUMBER: 198603344

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in one (1) out of two (2) bathrooms had comet cleaner unlocked under bathroom sink which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/14/2024
Plan of Correction
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Caregiver removed and locked comet cleaner up during inspection. Administrator will go over training and create log to email LPA.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Tony Vasallo
LICENSING EVALUATOR NAME:Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/14/2024 08:21 AM - It Cannot Be Edited


Created By: Christian Gutierrez On 08/13/2024 at 10:12 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. JUDE'S ELDER CARE II
FACILITY NUMBER: 198603344

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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 observatio, the licensee did not comply with the section cited above in one (1)out of two bathrooms water temperature measured at 96.2 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/27/2024
Plan of Correction
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Administrator adjusted water heater and will create log to test water and email LPA water log.
Deficiency Dismissed
Type B
Section Cited
CCR
87412(g)
Personnel Records
(g) All personnel records shall be maintained at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above Administrator did not keep personnel files at facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/27/2024
Plan of Correction
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Administrator agrees to keep files at faclity and will submit an email to LPA stating this.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2024


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 II
FACILITY NUMBER: 198603344
VISIT DATE: 08/13/2024
NARRATIVE
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Five (5) Staff files were reviewed and included Criminal clearance record, CPR/training, and health screening with TB. Administrator did not keep personnel files at facility deficiency cited. Five (5) Client files were reviewed and included physicians report, TB clearance. Fire/earthquake drill was conducted on August 3rd, 2024. Infectious control plan was reviewed. The medications are centrally stored and locked in a cabinet in dining area. The facility uses the Medication Administration Record (MAR) log to document medications given. LPA reviewed medications for all clients, and they are being administered as prescribed by the physician.

Deficiencies have been noted on LIC 809D under Title 22 Regulations. Exit interview was conducted and a copy of this report, LIC 809D and appeal rights were provided to Melinda Nofuente.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024
LIC809 (FAS) - (06/04)
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