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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004363
Report Date: 06/20/2024
Date Signed: 06/20/2024 11:53:43 AM

Document Has Been Signed on 06/20/2024 11:53 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ST. FRANCIS HOME FOR THE ELDERLY IIFACILITY NUMBER:
306004363
ADMINISTRATOR/
DIRECTOR:		RUNETTE CATIBOGFACILITY TYPE:
740
ADDRESS:11842 FOSTER ROADTELEPHONE:
(562) 637-3392
CITY:ROSSMOORSTATE: CAZIP CODE:
90720
CAPACITY: 6CENSUS: 6DATE:
06/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Runette CatibogTIME VISIT/
INSPECTION COMPLETED:
12:05 PM
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On June 20, 2024, at 8:00am, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim was greeted and granted entry by Caregiver Lynrd Suba, and explained the purpose of the visit.

The facility is licensed to operate for six (6) non-ambulatory and have a hospice waiver for four (4) residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) resident bedrooms, one (1) staff bedroom, two (2) bathrooms, living room, dining room, kitchen, detached 2-car garage, and an outside covered patio area.

LPA Kim toured indoor and outdoor of the physical plant with Caregiver Suba. Administrator Runette Catibog arrived and joined the tour at 8:41am. There are no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. All bedrooms were inspected: Resident Room 1, Resident Room 2, Resident Room 3, Resident Room 4, and Staff Room 1. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured at 105.8 degrees F and 110.0 degrees F. A comfortable temperature of 70 degrees F was maintained in the facility.

LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Emergency food, water, and supplies are stored in a closet. A working telephone (562-296-8859) remains available.

Evaluation Report Continues on LIC 809-C

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE: DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ST. FRANCIS HOME FOR THE ELDERLY II
FACILITY NUMBER: 306004363
VISIT DATE: 06/20/2024
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During the visit, LPA Kim observed the facility's infection control practices, plan of operation, and screening protocols for visitors, staff, and residents. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. First Aid Kit contained all the necessary elements. The facility has one (1) fire extinguishers that is charged and mounted in the kitchen, smoke detectors, and carbon monoxide detectors were operable. The facility conducted a fire/safety drill on April 8, 2024, and drills are conducted quarterly.

LPA conducted an audit of resident files (R1-R6), staff files (S1-S7), and medication and medication administration review that were all in order and complete. LPA Kim conducted three (3) staff interviews.

No deficiencies were cited during this inspection visit.

An exit interview was conducted, and a copy of this report was provided to Administrator Runette Catibog.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
LIC809 (FAS) - (06/04)
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