198601983-10-7-2024-11-AS-JCAN-D9PPFM-20241003111657

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601983
Report Date: 10/03/2024
Date Signed: 10/07/2024 08:32:58 AM

Document Has Been Signed on 10/07/2024 08:32 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	ST ANTHONY'S CARE HOME II		FACILITY NUMBER:	198601983
ADMINISTRATOR:	SOLETA,BEULAH		FACILITY TYPE:	740
ADDRESS:	1724 W 254TH STREET		TELEPHONE:	(310) 530-9842
CITY:	LOMITA	STATE: CA	ZIP CODE:	90717
CAPACITY:	6	CENSUS: 4	DATE:	10/03/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:10 AM
MET WITH:	Administrator Kenneth Soleta		TIME COMPLETED:	11:30 AM

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 10/03/2024 at 08:00 AM, Licensing Program Analyst LPA) Jose Calderon conducted an unannounced annual inspection visit at the St. Anthony’s Care Home II Facility. LPA Calderon was allowed entry into the facility by Administrator Kenneth Soleta. Administrator Kenneth Soleta asked infection control questions and took LPA Calderon temperature prior to entering the facility. The facility is licensed to operate for six (6) non-ambulatory residents ages 60 and above. Currently, there are four (4) residents residing in the facility, between the age of 60 and above. LPA Calderon explained to Administrator Kenneth Soleta, the purpose of the one-year Annual Inspection visit, and escorted LPA Calderon on a tour of the entire inside and outside facility grounds. As part of the inspection, LPA Calderon reviewed: Four (4) client service records, four (4) client medication records (MAR), four (4) staff records, and inspected the inside facility and outside grounds. LPA Calderon interviewed four (4) clients and four (4) staff members for visit. The facilities’ last fire drill was conducted on 09/03/2024. The one-story residential home consists of six (6) client bedrooms, three (3) client bathrooms, living room, dining room, kitchen, staff room, office area, attached garage with washer and dryer/ storage area, backyard with table and chairs. No weapons are stored or found on the premise grounds. Kitchen was inspected and observed to be clean and operational. A two-day supply perishable and seven-day supply of non-perishable foods are present in the facility. Emergency Water Storage is in the staff room area.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

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 II	FACILITY NUMBER: 198601983
	VISIT DATE: 10/03/2024

NARRATIVE

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During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and clients, sanitizing stations (Located in common areas and restrooms). LPA observed staff and clients were NOT wearing face coverings. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).

LPA Calderon advised the Administrator Kenneth Soleta 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.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA Calderon did not observe deficiencies therefore no citations were issued at this time. Annual Licensing Fee is CURRENT. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Administrator Kenneth Soleta.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

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 II	FACILITY NUMBER: 198601983
	VISIT DATE: 10/03/2024

NARRATIVE

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LPA Calderon observed that all facility rooms are clean and in good repair. A comfortable temperature was observed, and the facility has central air and heating. LPA Calderon observed the following during inspection of client’s rooms: mattresses are in good condition, adequate lighting present, plenty of dresser/closet space is present, and all bed linens present. All bedrooms contain furniture, lighting fixtures and personal storage space as required, all beds have the required amount of linen and mattress covers, LPA Calderon observed fully stocked closet with bedding, towels, and toiletries supplies. Bathroom fixtures are clean, in good repair, and working properly and contain the required nonskid mats and grab bars. LPA Calderon observed bathrooms were found to be within Title 22 regulation. Bathroom #1 hot water temperature properly measured at 117 degrees Fahrenheit, bathroom #2 hot water temperature properly measured at 115 degrees Fahrenheit, and bathroom #3 hot water temperature properly measured at 113 degrees Fahrenheit. Kitchen hot water temperature properly measured at 117 degrees Fahrenheit. Facility ten (10) Carbon Monoxide and ten (10) Smoke Detectors hard wired and connected were tested and are working properly. The facility two (2) Fire Extinguisher was checked and found to be fully charged and accessible. All exit doors in the facility have alarm systems. The facility has a working landline telephone. All toxins and knifes are locked/secured and inaccessible to clients. Medications are centrally stored and in a locked storage cabinet. Facility three (3) first aid kits is fully stocked with manuals was checked and in order. Outside grounds were toured and no bodies of water were observed. All Exits/ Walkways around the home were free of debris and hazards. Outside patio accessible to clients. Four (4) client files were reviewed and found to be complete. LPA Calderon reviewed four (4) resident medications (MAR) and they were all found to be administered according to doctor's orders. four (4) staff files were checked and have the required documents. LPA Calderon noted the Administrator Kenneth Soleta Certification # 7010689740 expiration date of 08/26/2025 was valid at time of inspection. The facility does not handle client's money/cash resources and no Surety bond is needed. Commercial General Liability Policy #PCI4419729704 policy period from 07/13/2024 to 07/13/2025 underwritten by Primary Care Insurance Company, coverage 1,000,000/3,000,000 is valid at time of inspection. Administrator Kenneth Soleta to email LPA Calderon a full copy of the commercial insurance policy including all endorsements no later than 10/15/2024. All the required documents are posted in the facility in a clearly visible area.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

LIC809 (FAS) - (06/04)

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