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Inspection visit

Follow-up on corrections

ST PAUL'S MANORLicense 3708005587 citations on this visit
7 citations recorded

Inspector’s narrative

What the inspector wrote

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management Visit to cite deficiencies identified during a separate complaint investigation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Tim Jeffers and Resident Services Coordinator Carol Braun. The Department’s investigation involved records review and interviews of pertinent facility managers, other sources, and Resident #1 (R1). [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] The evidence showed on 04/10/2025, Licensee served a 30-day notice eviction letter upon R1, but did not notify CCLD within five (5) days of service, as required. The Department subsequently obtained a copy of the eviction letter, finding it deficient in the following ways: -Licensee did not specify the “effective date of the eviction,” as required. -Licensee cited in the letter R1’s “continued defiance” of facility rule(s), but did not specify in the letter which specific rule(s) were violated nor provide “specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons,” as required. -Licensee did not specify in the letter “resources available to assist in identifying alternative housing and care options,” to include “referral services” and “case management organizations,” as required. -Licensee did not include “a statement informing residents of their right to file a complaint with the licensing agency…including the name, address and telephone number of the licensing office with whom the licensee normally conducts business, and the State Long Term Care Ombudsman office,” as required. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] -Licensee did not include the required disclaimer paragraph from California Health and Safety Code Section 1569.683(a)(4), which reads, "In order to evict a resident who remains in the facility after the effective date of the eviction, the residential care facility for the elderly must file an unlawful detainer action in superior court and receive a written judgment signed by a judge. If the facility pursues the unlawful detainer action, you must be served with a summons and complaint. You have the right to contest the eviction in writing and through a hearing." Additionally, during a facility evaluation visit on 09/18/2023, LPA learned that Licensee had about six months earlier installed a new facility administrator / Executive Director, Staff #1 (S1), who was different from the administrator on record with CCLD (the latter person was no longer working at the facility). (Per regulation, Licensees must notify the Department in writing within thirty (30) days of hiring a new administrator.) Instead of citing Licensee for failing to notify CCLD as required, the Department recognized S1 was adjusting to their new role and afforded Licensee an opportunity to self-correct. LPA issued written Technical Assistance (TA) to Licensee providing detailed instructions on the specific paperwork/forms which Licensee needed to submit to the Department by 09/28/2023 to change the administrator on record to S1. However, as of LPA’s 05/06/2025 site visit, Licensee still had not corrected the violation, so a deficiency was issued for it. Seven (7) deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D pages). Plans of Correction were jointly developed with the Licensee. An exit interview was conducted with Jeffers and Braun, to whom a copy of this report, the LIC 809-D pages, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

Citations

9 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 87224(a)(3)Type B

    87224 Eviction Procedures: “(a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5)… (3) Failure of the resident to comply with general policies of the facility. Said general policies must be in writing, must be for the purpose of making it possible for residents to live together and must be made part of the admission agreement.” This requirement was not met, as evidenced by: Based on records review and interviews, Licensee served an eviction notice to 1 of 106 residents (R1) for failure to comply with a general policy of the facility, but said policy was not for the purpose of making it possible for residents to live together and was not fully disclosed at the time the admissions agreement was signed. This posed a potential personal rights risk to persons in care.

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  • 87468.2(a)(14)Type B

    87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: “(a) …residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (14) To reasonable accommodation of their individual needs and preferences in all aspects of life in the facility…” This requirement was not met, as evidenced by: Based on records review and interviews, Licensee did not reasonably accommodate the individual need/preference of 1 of 106 residents (R1) regarding their life at the facility, when the specific accommodation that R1 requested was reasonable with regard their safety and those of peers. This posed a potential personal rights risk to persons in care.

  • 87211(g)Type B

    87211 Reporting Requirements: “(g) The licensee shall notify the Department, in writing, within thirty (30) days of the hiring of a new administrator. The notification shall include the following: (1) Name and residence and mailing addresses of the new administrator. (2) Date he/she assumed his/her position. (3) Description of his/her background and qualifications, including documentation of required education and administrator certification. (A) A photocopy of the documentation is acceptable.” This requirement was not met, as evidenced by: Based on LPA observation and manager interviews: Licensee did not notify the Department in writing within thirty (30) days of the hiring of a new administrator. This posed a potential health, safety, and personal rights risk to 1 of 106 residents (R1 though R106) in care.

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  • 87224(d)Type B

    Notice to quit must state specific reasons and details

    87224 Eviction Procedures : “(d) The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons.” This requirement was not met, as evidenced by: Based on records review, in the notice to quit regarding 1 of 106 residents (R1), Licensee did not set forth specific facts to include date, place, witnesses, and circumstances concerning the reason(s) for eviction. This posed a potential personal rights risk to persons in care.

  • 87224(d)(1)(A)Type B

    87224 Eviction Procedures : “(d)(1) The notice to quit shall include the following information: (A) The effective date of the eviction.” This requirement was not met, as evidenced by: Based on records review, in the notice to quit regarding 1 of 106 residents (R1), Licensee did not include the effective date of the eviction. This posed a potential personal rights risk to persons in care.

  • 87224(d)(1)(B)Type B

    87224 Eviction Procedures : “(d)(1) The notice to quit shall include the following information: (B) Resources available to assist in identifying alternative housing and care options…” This requirement was not met, as evidenced by: Based on records review, in the notice to quit regarding 1 of 106 residents (R1), Licensee did not include resources available to assist in identifying alternative housing and care options, to include referral services and case management organizations. This posed a potential personal rights risk to persons in care.

  • 87224(d)(1)(C)Type B

    87224 Eviction Procedures : “(d)(1) The notice to quit shall include the following information: (C) A statement informing residents of their right to file a complaint with the licensing agency, as specified in Section 87468, subsection (a)(4), including the name, address and telephone number of the licensing office with whom the licensee normally conducts business, and the State Long Term Care Ombudsman office.” This requirement was not met, as evidenced by: Based on records review, in the notice to quit regarding 1 of 106 residents (R1), Licensee did not include a statement informing residents of their right to file a complaint with the licensing agency, as specified in Section 87468, subsection (a)(4), including the name, address and telephone number of the licensing office with whom the licensee normally conducts business, and the State Long Term Care Ombudsman office. This posed a potential personal rights risk to persons in care.

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  • 87224(d)(1)(D)Type B

    87224 Eviction Procedures : “(d)(1) The notice to quit shall include the following information: (D) The following exact statement as specified in Health and Safety Code Section 1569.683(a)(4): ‘In order to evict a resident who remains in the facility after the effective date of the eviction, the residential care facility for the elderly must file an unlawful detainer action in superior court and receive a written judgment signed by a judge. If the facility pursues the unlawful detainer action, you must be served with a summons and complaint. You have the right to contest the eviction in writing and through a hearing.’” This requirement was not met, as evidenced by: Based on records review, in the notice to quit regarding 1 of 106 residents (R1), Licensee did not include the following exact statement as specified in Health and Safety Code Section 1569.683(a)(4): “In order to evict a resident who remains in the facility after the effective date of the eviction, the residential care facility for the elderly must file an unlawful detainer action in superior court and receive a written judgment signed by a judge. If the facility pursues the unlawful detainer action, you must be served with a summons and complaint. You have the right to contest the eviction in writing and through a hearing.” This posed a potential personal rights risk to persons in care.

    Read full inspector narrative
  • 87224(f)Type B

    Eviction report must be filed within five days

    87224 Eviction Procedures : “(f) A written report of any eviction shall be sent to the licensing agency within five (5) days.” This requirement was not met, as evidenced by: Based on records review, Licensee did not send a written report of eviction regarding 1 of 106 residents (R1) to the licensing agency within five (5) days. This posed a potential personal rights risk to persons in care.

FAQ · About this visit

Common questions about this visit

What happened during the May 8, 2025 inspection of ST PAUL'S MANOR?

This was an other inspection of ST PAUL'S MANOR on May 8, 2025. 7 citations were issued: 7 Type B.

Were any citations issued to ST PAUL'S MANOR on May 8, 2025?

Yes, 7 citations were issued (0 Type A, 7 Type B). The first citation was for: "87224 Eviction Procedures: “(a) The licensee may evict a resident for one or more of the reasons listed in Section 87224..."

What type of inspection was this?

This was an other inspection. other inspections are conducted by CCLD as part of their licensing oversight.

SourceView on CCLDView original report

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.