197608255-5-15-2023-11-AS-DESA-CRUUET-20230515153140

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608255
Report Date: 05/15/2023
Date Signed: 05/15/2023 03:32:08 PM

Document Has Been Signed on 05/15/2023 03:32 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:	SAN ANTONIO RESIDENTIAL FACILITY		FACILITY NUMBER:	197608255
ADMINISTRATOR:	FRANCIS SORIANO		FACILITY TYPE:	740
ADDRESS:	3013 S. VICTORIA AVENUE		TELEPHONE:	(323) 733-2835
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90016
CAPACITY:	6	CENSUS: 2	DATE:	05/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:51 AM
MET WITH:	Francis Soriano, Administrator		TIME COMPLETED:	03:45 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 05/15/2023 Licensing Program Analyst (LPA) David España and Licensing Program Manager (LPM) Ulysses Coronel conducted an unannounced visit to San Antonio Residential Facility. The purpose of today’s visit was to conduct the annual inspection. LPA was met by Milagros Soriano and Mariavisit Alindayu. Licensee prefers to serve clients 60 and above. All 2 client bedrooms are fire cleared for 6 non-ambulatory residents. There are currently two (2) South Central Regional Center clients in placement. All (2) clients are ambulatory. The facility is a single-story structure located in a residential neighborhood. It consists of the following: Three (3) resident bedrooms, one (1) staff bedroom, one (1) resident bathroom, one (1) staff bathroom, living room / dining room, and kitchen. LPAs inspected resident bedroom furniture, bed linens and closet space to accommodate each resident. Resident bathroom was checked. LPAs inspected the toilet and water faucet, grab bars, shower and a non-skid mat was in place. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked under the sink and in the detached garage. LPA and administrator toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. 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. A comfortable temperature is maintained in the facility. LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is enough perishable and non-perishable food available which is stored properly. Fire extinguishers were charged, smoke detectors and Carbon Monoxide were operable.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023

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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Document Has Been Signed on 05/15/2023 03:32 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: SAN ANTONIO RESIDENTIAL FACILITY	FACILITY NUMBER: 197608255
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87616(b)(1)

Exceptions for Health Conditions

(b) Written requests shall include, but are not limited to, the following: (b) Written requests shall include, but are not limited to, the following: (1) Documentation of the resident's current health condition including updated medical reports, other documentation of the current health, prognosis, and expected duration of condition. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above. During record review Licensing Program Analyst (LPA) David España and Licensing Program Manager (LPM) Ulysses Coronel and Administrator did not observe annual Phycisian's for both clients in care, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/25/2023
	Plan of Correction
1 2 3 4	The administrator/licensee agreed to have all annual medical reports for all clients in care ensuring resident safety. The licensee shall submit plan of correction to ensure cited deficiency do no reoccur at the facility. The administrator of records shall update the resident's/staff's needs and services plans on 05/25/2023 due date.

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: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023

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: SAN ANTONIO RESIDENTIAL FACILITY	FACILITY NUMBER: 197608255
	VISIT DATE: 05/15/2023

NARRATIVE

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Kitchen was checked and observed. Perishable and non-perishable food supply was checked. Cleaning solutions, hazardous items, and medications were observed, locked away from clients. Outside grounds were toured. No body of water observed. Walkways around the home were observed and clear for any egress. There are no security bars or weapons on the premises. LPA observed screening protocols for visitors, staff and residents, sanitizing stations (Located in common areas and restrooms). LPA observed staff were wearing face coverings, and all required postings were present throughout the facility.

LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

During today’s visit there was one deficiency observed, Title 22 Regulation are being cited please see LIC809-D.

Exit interview held. A copy of the report and appeal rights was provided to Francis Soriano.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023

LIC809 (FAS) - (06/04)

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