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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603344
Report Date: 10/22/2024
Date Signed: 10/22/2024 02:29:39 PM

Document Has Been Signed on 10/22/2024 02:29 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 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:
10/22/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:22 PM
MET WITH:Caregiver Melinda NofuenteTIME VISIT/
INSPECTION COMPLETED:
02:35 PM
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The purpose of this report addresses a deficiency that was cited on 08/13/2024. On this day facility was cited for CCR 87412(g) it was appealed and dismissed by department. LPA Gutierrez met with Caregiver Melinda Nofuente and Administrator was notified by phone. A copy of this report was left with Caregiver.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2024
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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