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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603769
Report Date: 06/30/2025
Date Signed: 06/30/2025 10:14:36 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/26/2025 and conducted by Evaluator Christian Gutierrez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250626163949
FACILITY NAME:ST. JUDE'S HOME FOR THE ELDERLY IIFACILITY NUMBER:
198603769
ADMINISTRATOR:CORSENTINO, ANTOINETTEFACILITY TYPE:
740
ADDRESS:4944 BUFFINGTON ROADTELEPHONE:
(909) 263-3787
CITY:EL MONTESTATE: CAZIP CODE:
91732
CAPACITY:6CENSUS: 6DATE:
06/30/2025
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Caregiver Virgi VicenteTIME COMPLETED:
10:25 AM
ALLEGATION(S):
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Facility is not providing a refund to resident's responsible party as necessary.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christian Gutierrez conducted an unannounced complaint investigation regarding the above allegations. LPA was met by Caregiver Virgi Vicente. Administrator Terry McGee was notified by telephone.

The investigation consisted of the following: LPA Gutierrez requested and obtained copies of staff roster, resident roster, resident (R1) identification and emergency information, and admission agreement. LPA conducted interview with Administrator over the telephone.

SEE 9099C
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christian Gutierrez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 28-AS-20250626163949
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 HOME FOR THE ELDERLY II
FACILITY NUMBER: 198603769
VISIT DATE: 06/30/2025
NARRATIVE
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In regard to the allegation” Facility is not providing a refund to resident's responsible party as necessary”. It is alleged that after R1’s passing on April 10th, 2025, facility did not issue refund for rent. It was revealed during record review that admission agreement dated March 10th, 2024, that upon death of a resident within 15 days a refund will be issued. During interview with Administrator, it was reveled that admission agreement had not been followed and a refund was issued on June 23rd with a bank hold of June 30th, 2025.

Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 and Health and Safety Code.

An exit interview was conducted with Caregiver. A copy of the report and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christian Gutierrez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20250626163949
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 HOME FOR THE ELDERLY II
FACILITY NUMBER: 198603769
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/04/2025
Section Cited
CCR
87507(f)
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87507 Admission Agreements
(f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments.
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Administrator issued refund on June 23rd, 2025, with a bank hold until June 30th, 2025.
Administrator will send LPA by email a plan on how moving forward the admission agreement will be followed.
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This deficiency is evidenced by the following:
Administrator did not issue a refund within the 15 days of R1’s death.
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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.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christian Gutierrez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3