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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601983
Report Date: 10/27/2023
Date Signed: 10/28/2023 07:44:36 AM

Document Has Been Signed on 10/28/2023 07:44 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 IIFACILITY NUMBER:
198601983
ADMINISTRATOR:SOLETA,BEULAHFACILITY TYPE:
740
ADDRESS:1724 W 254TH STREETTELEPHONE:
(310) 530-9842
CITY:LOMITASTATE: CAZIP CODE:
90717
CAPACITY: 6CENSUS: 5DATE:
10/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:31 AM
MET WITH:BEULAH SOLETATIME COMPLETED:
05:15 PM
NARRATIVE
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On 10/27/2023, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with House Manager Myrna Dennis and explained the purpose of the visit. At around 11:15 AM, Administrator Beulah Soleta arrived and joined the visit.

The facility is licensed to operate for six (6) non-ambulatory elderly residents ages 60 and above. The facility is approved for two (2) hospice residents. The facility is a single-story structure located in a residential neighborhood. The facility consists of the following: six (6) resident's bedrooms, two (2) resident bathrooms, two (2) staff bedrooms, one (1) staff bathroom, a living room area, dining area, and kitchen. The washer and dryer are located next to one of the staff bedrooms. There is a shaded patio area with ample seating area for the residents. The facility does not handle residents’ cash resources. Facility Annual Fees are current during today’s visit. Administrator's certificate expires 4/1/2024.



At around 11:00 AM, LPA toured the inside and outside grounds of the facility with House Manager Myrna Dennis. Carbon monoxide and smoke detectors were tested and found to be operable. The last facility fire drill was on August 8, 2023. LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, and toxins were stored and not accessible to clients. The kitchen was inspected and there are sufficient two-day perishable and seven-day non-perishable food supplies.

There are no pools or bodies of water on the premises. There are no firearms on the premises or other dangerous weapons. Centrally stored medications are locked in a cabinet located in the medication room. The first aid kit has all required supplies. The facility has a written emergency disaster plan posted in the living room. The facility is maintained at a comfortable temperature. There are working lights or lamps in each room at the time of visit. There are grab bars for each toilet and shower used by residents. Showers have non-skid floors.



Report Continued in LIC 809-C
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2023
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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: ST ANTHONY'S CARE HOME II
FACILITY NUMBER: 198601983
VISIT DATE: 10/27/2023
NARRATIVE
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LPA observed the following deficiencies:

1. One resident (R3) is bedridden according to Physician's Report.

2. The hot water temperature in the residents' common bathroom was 146.0 degrees Fahrenheit.



3. Three residents don't have current Appraisal/Needs and Services Plan.

4. Two staff don't have health screening records/TB test records.

5. Three residents don't have TB test records.

6. Fire extinguishers were last serviced on 9/14/202.

Further inspection is needed. LPA will return to conduct additional inspection and to issue additional citations.

Some of the above deficiencies are being cited based on LPA observations, interviews conducted and records review in accordance with the California Code of Regulations, Title 22, see LIC809D. Civil penalty is being assessed.

An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left wit Administrator Beulah Soleta.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/28/2023 07:44 AM - It Cannot Be Edited


Created By: Lourdes Montoya On 10/27/2023 at 04:06 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: ST ANTHONY'S CARE HOME II
FACILITY NUMBER: 198601983

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(c)
Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above. LPA did not observe current appraisals for three residents (R, R2 & R5). This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/10/2023
Plan of Correction
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The administrator shall submit a copy of the resident's (R1, R2 & R5) current appraisals/Needs and Services Plan. Proof of Corrections shall be submitted to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date, 11/10/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/28/2023 07:44 AM - It Cannot Be Edited


Created By: Lourdes Montoya On 10/27/2023 at 04:34 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: ST ANTHONY'S CARE HOME II
FACILITY NUMBER: 198601983

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type A
Section Cited
CCR
87606(c)
(c) To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above. On 10/27/2023, LPA Montoya observed one resident (R3) is bedridden and the facility does not have fire clearance for bedridden. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/28/2023
Plan of Correction
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The administrator shall obtain a fire clearance for R3 and shall submit to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date.
Type A
Section Cited
CCR
87303(e)(2)
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F and not more than 120 degree F.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, Interview and record review, the licensee did not comply with the section cited above. The water temperature in the common bathroom for residents was measured at 146.0 degree F. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/28/2023
Plan of Correction
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The administrator shall adjust the water temperature to comply to this section of Title 22 as stated above. The administrator shall record the water temperature every two hours for the next twenty four hours and shall submit the record to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date, 10/28/2023.
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:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2023


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