197606350-11-19-2022-11-AS-EDAT-CLBS9S-20221119124112

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606350
Report Date: 11/19/2022
Date Signed: 11/19/2022 12:42:26 PM

Document Has Been Signed on 11/19/2022 12:42 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY 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:	11/19/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:02 AM
MET WITH:	Kenneth Soleta		TIME COMPLETED:	12:59 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 11/19/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit with a primary focus on Infection Control measures using the CARE Inspection Tool. LPA met with administrator Kenneth Soleta and explained the purpose of today’s visit. The facility is licensed to operate for six (6) elderly residents and cleared for (4) non-ambulatory and (2) bedridden ages 60 and above. The facility is approved for one (1) hospice resident. The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) residents' rooms, one (1) bathroom, a living area, a dining area, a kitchen, and an outside covered patio area. LPA 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, and storage for the resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of the visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 115.4 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 the 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 and maintained properly. The facility has one (1) fire extinguisher that was charged, and smoke detectors and carbon monoxide were operable. LPA reviewed Medication Administration Records (MAR) revealed to be accurate and maintained in order. The facility conducted a Fire/Safety Drill on 10/03/22. A working landline telephone remains available. The facility has current liability insurance effective 07/13/22 - 07/13/23. Evaluation Report Continues on LIC 809-C

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2022

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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ST. ANTHONY'S CARE HOME	FACILITY NUMBER: 197606350
	VISIT DATE: 11/19/2022

NARRATIVE

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INFECTION CONTROL:
During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed staff 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 and staff vaccination records were conducted. The facility has a Mitigation Plan Report on file with CCLD. All staff had current (CPR/First-Aid) training certificates.

DEFICIENCIES:
Based on interviews, observation, and record reviews, LPA identified a staff # (S3) without Criminal Record Clearance from the State of California. (S3) had a Criminal Record Clearance from the state of Arizona which is not valid. LPA identified residents #1-#3 with dementia who did not have ongoing/annual appraisals on file.

Deficiencies are cited on LIC 809D.

An exit interview was conducted and a copy of this report was provided to Kenneth Soleta.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/19/2022 12:42 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ST. ANTHONY'S CARE HOME	FACILITY NUMBER: 197606350
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(1)

Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility. (1) Obtain a California clearance or a criminal record exemption as required by the Department. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on (observation) (record review)], the licensee did not comply with the section cited above. LPA identified staff #3 did not have a criminal background clearance check and had being working at the facility for (5) days. This volation poses an immediate health and safety to residents in care.
	POC Due Date: 11/21/2022
	Plan of Correction
1 2 3 4	Licensee will adhere to Title 22 Section 87355. (S3) will not return to work until he has obtained a clearance from state of California, or a criminal record exemption as required by the CCLD by POC 11/21/22. A civil penalty in the amount of $500.00 was issued. - Citation was cleared during visit (S3) was removed from the facility.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2022

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 11/19/2022 12:42 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ST. ANTHONY'S CARE HOME	FACILITY NUMBER: 197606350
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(c)(6)

87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (record review), the licensee did not comply with the section cited above. LPA identified residents #1-#3 who is diagnosed with dementia did not have ongoing appraisals. The violaiton poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/05/2022
	Plan of Correction
1 2 3 4	Licensee will adhere to Title 22 Section 87705. LIcensee will ensure that all residents with dementia have ongoing annual appraisals. Licensee will send proof of correction by email or fax at 323-981-1781 by due date: 12/05/22.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2022

LIC809 (FAS) - (06/04)

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