197606350-10-25-2023-11-AS-LVIS-CWXPNJ-20231025112801

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606350
Report Date: 10/25/2023
Date Signed: 10/25/2023 11:28:05 AM

Document Has Been Signed on 10/25/2023 11:28 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
EL SEGUNDO ASC, 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: 5	DATE:	10/25/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Director Beulah Soleta		TIME COMPLETED:	11:37 AM

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On 10/25/23, Licensing Program Analyst (LPA) Lizeth Villegas conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Director Beulah 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. Current census is (5).

The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) residents' rooms, one (1) resident bathroom, (1) staff restroom, a linen/hygiene supply closet, a living area, a dining area, a kitchen, a small staff work area, an outside covered patio area and a detached garage that houses a washer and dryer, additional refrigerator and freezer, emergency food and water supplies. Garage also serves as additional storage space.

LPA conducted a records review of 2 staff records, 3 resident records, and 3 medication Administration Records. No discrepancies observed. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The last fire was conducted on 10/02/23, (1) fire extinguisher fully charged and observed throughout the facility, carbon monoxide and smoke detectors observed and are operational. Landline and internet service was observed. The facility has a current/activate liability insurance.

Client bedrooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Bathroom toilets and water faucets worked properly, shower was free of mold/mildew, and there are sufficient toiletries accessible to residents. The water temperature properly measured between 105-120 F..

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lizeth Villegas	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ST. ANTHONY'S CARE HOME	FACILITY NUMBER: 197606350
	VISIT DATE: 10/25/2023

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During the visit, LPA observed screening protocols for visitors and staff, and sanitizing stations in common areas and restrooms. LPA observed staff wearing face coverings. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Toxins and knifes were observed to be locked and inaccessible to residents. Exits/ Walkways around the facility were free of debris and hazards.

During today’s visit no discrepancy were observed.

Exit interview conducted with Director Beulah Soleta, and a copy of this report was provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lizeth Villegas	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

LIC809 (FAS) - (06/04)

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