197606350-9-28-2024-11-AS-EDAT-D9JVGB-20240928162517

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606350
Report Date: 09/28/2024
Date Signed: 09/28/2024 04:25:22 PM

Document Has Been Signed on 09/28/2024 04:25 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

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: 6	DATE:	09/28/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:11 AM
MET WITH:	Kenneth Soleta		TIME COMPLETED:	01:05 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 09/28/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit 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. Currently the facility has (2) hospice resident in care. 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 111.4 F. A comfortable temperature of 70 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 09/02/24. A working landline telephone remains available. The facility has current liability insurance effective 07/13/24 - 07/13/25. Evaluation Report Continues on LIC 809-C

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2024

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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: ST. ANTHONY'S CARE HOME	FACILITY NUMBER: 197606350
	VISIT DATE: 09/28/2024

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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.

LPA conducted an audit of resident #1-#6 (R1-R6) service files, and staff #1-#5 (S1-S5) personnel files were in order. The administrator certificate for Kenneth Soleta effective #7010689740 08/27/2023- 08/26/2025 and Reynaldo Soleta effective # 7035959740 07/28/2023- 07/28/2025.. The facility is current on CCLD annual dues. An invoice was left with administrator Kenneth Soleta.

Advisory - Technical Violations (see LIC 9102)

No deficiencies cited during this inspection visit.

An exit interview conducted with Kenneth Soleta, and a copy of the report is provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2024

LIC809 (FAS) - (06/04)

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