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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275200750
Report Date: 11/09/2022
Date Signed: 11/22/2022 08:55:33 AM


Document Has Been Signed on 11/22/2022 08:55 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:SANTO NINO RESIDENTIAL CARE HOMEFACILITY NUMBER:
275200750
ADMINISTRATOR:FONTEJON, DOMINADORFACILITY TYPE:
740
ADDRESS:965 HANCOCK ST.TELEPHONE:
(831) 443-9573
CITY:SALINASSTATE: CAZIP CODE:
93906
CAPACITY:6CENSUS: 5DATE:
11/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Licensee Rodriga FontejonTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit today for the facility’s annual inspection. LPA met with Administrator Rodrigo Fontejon, Continual Administrator's Certification expires 01/26/2024. There are currently 5 residents who reside at this home and there is 0 residents on hospice at this time. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, garage and outdoor areas. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable.

Fire extinguisher is within the safety regulation period. Water temperature was tested at 122 degrees. Toxins and cleaning supplies are locked and inaccessible. LPA ensured all staff present is background cleared.
LPA Hurt observed the hallway in the entrance outside of Resident 1's bedroom to have a urine, body odor smell. LPA observed the window screen located outside the living room area to be torn. LPA observed the facilities first aid kid to be incomplete, and missing a guide. LPA Hurt was not screened for COVID 19 symptoms upon entering the facility, and Staff 1 was not wearing a mask. Administrator Rodrigo Fontejon did not have a copy of COVID 19 vaccine card or exemption on file.

The following deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22.

LPA's requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing.

Exit interview conducted with Licensee Rodriga Fontejon and copy of report left at facility
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2022
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 11/22/2022 08:55 AM - 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
CCLD Regional Office,
, CA


FACILITY NAME: SANTO NINO RESIDENTIAL CARE HOME
FACILITY NUMBER: 275200750

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in the facility entryway smelled of urine, and body odor coming from the bedroom of Resident 1 located to the right which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/23/2022
Plan of Correction
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Licensee agrees to ensure Resident 1's bedroom does not cause the facility entry to have any odors and send proof to LPA by POC date of 11/23/2022.
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(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 (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in the water in facilty bathroom in hallway measured to be 122 degrees which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/16/2022
Plan of Correction
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Licensee agrees to turn down the water temperature to ensure it does not reach more than 120 degrees and send proof to LPA Hurt by 11/06/2022 POC date.

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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2