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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603672
Report Date: 08/24/2024
Date Signed: 08/24/2024 04:03:59 PM

Document Has Been Signed on 08/24/2024 04:03 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ST. CHRISTOPHER AND JUDE HOME FOR THE ELDERLYFACILITY NUMBER:
198603672
ADMINISTRATOR/
DIRECTOR:		CORSENTINO, ANTOINETTEFACILITY TYPE:
740
ADDRESS:1506 S. CANDISH AVENUETELEPHONE:
(626) 335-0429
CITY:GLENDORASTATE: CAZIP CODE:
91740
CAPACITY: 6CENSUS: 5DATE:
08/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:05 AM
MET WITH:Administrator AntoinetteTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced required annual inspection visit and was greeted by Back up-Administrator Barbara Mitchell. LPA Ramirez explained the purpose of the visit. The facility is located on a residential street and is a single store dwelling.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected four (4) resident rooms. All resident bedrooms contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. LPA Ramirez observed grab bars near toilets and inside showers. LPA Ramirez observed no-slip mat in showers. Facility has video surveillance inside common areas and outside perimeter of the facility.

Food Service: LPA Ramirez observed sufficient supply of nonperishables for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0-degree F (-17.7 degree C), and refrigerators with maximum temperature of 40-degree F. (4 degree C). LPA Ramirez observed bottom kitchen cabinet drawer to be in disrepair and not functioning to it’s original design.

Planned Activities: LPA Ramirez observed board games, magazines, and other activities for residents.

Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed facility land line.

Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. Last documented emergency drills were conducted on 06/23/2024. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility.




See 809-C
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2024
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ST. CHRISTOPHER AND JUDE HOME FOR THE ELDERLY
FACILITY NUMBER: 198603672
VISIT DATE: 08/24/2024
NARRATIVE
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Residents with Special Needs: Pool was observed to be inaccessible to residents in care. LPA Ramirez observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. LPA Ramirez observed several oxygen tanks in resident rooms secured in stands. Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Auditory devices were observed to be in working order.

Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication rooms and in bubble packs and/or original containers. The facility uses the Medication Administration Record (MAR) log to document medications given. The facility provides incidental medical services.

Staffing: Administrator Certificate for Antoinette Corsentino expires 09/18/2025. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed CPR and First Aid for two (2) out of the three (3) personnel records reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for three (3) out of the three (3) personnel records reviewed. Two (2) out of the three (3) staff completed required annual training. LPA Ramirez did not observe required annual training for R1.

Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place.



Operational Requirements: The fire clearance is approved for six (6) non-ambulatory. This facility may retain no more than six (6) hospice residents. There were two (2) residents under hospice care during inspection.

Resident Records/Incident Reports: LPA reviewed Resident files for five (5) residents in care. Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed. LPA Ramirez did not observe annual medical assessment for R5.

Three (3) deficiencies were observed during visit. Exit interview conducted. A copy of this report, 809-D and appeals rights was provided via email.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/24/2024 04:03 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 08/24/2024 at 01:55 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. CHRISTOPHER AND JUDE HOME FOR THE ELDERLY
FACILITY NUMBER: 198603672

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

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 5 out of 5 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/07/2024
Plan of Correction
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Licensee will repair cabinet and send picture proof via email.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, R1 did not complete required annual training hours, the licensee did not comply with the section cited above in 5 out of 5 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/07/2024
Plan of Correction
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Licensee will have S1 complete annual training hours and send proof of retraining via email.
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:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 08/24/2024 04:03 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 08/24/2024 at 01:55 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. CHRISTOPHER AND JUDE HOME FOR THE ELDERLY
FACILITY NUMBER: 198603672

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, R5 did not have annual medical assessemnt completed, the licensee did not comply with the section cited above in 1 out of 5 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/07/2024
Plan of Correction
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Licensee will have R5 complete medical assessment and send proof via email by 9/7/24.
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:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2024


LIC809 (FAS) - (06/04)
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