197606350-9-15-2021-11-AS-EDAT-C6W6D3-20210915204224

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606350
Report Date: 09/15/2021
Date Signed: 09/15/2021 08:43:22 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME:	ST. ANTHONY'S CARE HOME		FACILITY NUMBER:	197606350
ADMINISTRATOR:	BEULAH SOLETA		FACILITY TYPE:	740
ADDRESS:	507 WEST 215TH STREET		TELEPHONE:	(424) 271-7071
CITY:	CARSON	STATE: CA	ZIP CODE:	90745
CAPACITY:	6	CENSUS: 4	DATE:	09/15/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:18 AM
MET WITH:			TIME COMPLETED:	12:08 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 09/15/21, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with the administrator and explained to Beulah Soleta the purpose of today’s visit. The facility is licensed to operate for six (6) residents of which four(4) may be non-ambulatory and two (2) bedridden with one (1) hospice. The facility is approved to serve adults over the age of 60 and above. The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) resident's rooms, two (2) common bathrooms, living area, dining area, kitchen, and outside covered patio area. LPA and administrator toured the physical plant. There were 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 resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 115.6 F. A comfortable temperature of 73 degrees was maintained in the facility. LPA 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 sufficient perishable and non-perishable food available maintained properly. A fire extinguisher was charged, smoke detectors and carbon monoxide were operable. A landline telephone was in working condition. The facility conducted a fire/disaster drill on 09/05/21. Evaluation Report Continues on LIC 809-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021

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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: ST. ANTHONY'S CARE HOME	FACILITY NUMBER: 197606350
	VISIT DATE: 09/15/2021

NARRATIVE

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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of the resident's vaccination results was conducted. The facility has a Mitigation Plan Report on file with CCLD.

Advisory Notes - Technical Assistance was issued, please see LIC9102-AN.

No deficiencies were cited during this inspection visit.

An exit interview was conducted and a copy of this report was provided to Beulah Soleta by email.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021

LIC809 (FAS) - (06/04)

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