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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005768
Report Date: 05/30/2024
Date Signed: 05/30/2024 11:51:53 AM

Document Has Been Signed on 05/30/2024 11:51 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:SAINT AGNES CAREFACILITY NUMBER:
306005768
ADMINISTRATOR/
DIRECTOR:		ROSARIO, ROBERTO DELFACILITY TYPE:
740
ADDRESS:4931 CARTHAGE STREETTELEPHONE:
(657) 258-9152
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY: 6CENSUS: 6DATE:
05/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:35 AM
MET WITH:Roberto Del RosarioTIME VISIT/
INSPECTION COMPLETED:
12:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA was greeted and granted entry by Licensee Roberto Del Rosario and explained the purpose of the inspection.

During the inspection LPA and Licensee conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, garage and observed the following:

This is a two-story home with six resident bedrooms, one staff bedroom, three bathrooms, and attached two-car garage on the first floor. The second story is used solely as staff quarters. All resident bedrooms had the required furnishings. LPA observed all resident beds had linens and blankets. The backyard has a shaded sitting area. LPA observed residents resting in their respective bedrooms. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested between 116.6-118.0 degrees Fahrenheit.

LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Electric stove, microwave, washer, and dryer were all inspected and observed to be operable. Sharps were observed locked in a kitchen cabinet. All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents. Medication cabinet was observed to be locked, however, resident medication is pre-prepared a day in advanced and poured into a separate plastic daily medication organizer.

Administrator (AD) Lester Del Rosario arrived at 9:30 a.m. to assist with the inspection. LPA reviewed six resident files and three staff files. Staff files did not contain any documentation for initial 6 hours of hands-on required medication shadowing training. AD stated training was conducted upon hire but was not originally documented. (Cont. LIC809-C)

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 05/30/2024 11:51 AM - It Cannot Be Edited


Created By: Claudia Gutierrez On 05/30/2024 at 11:19 AM
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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SAINT AGNES CARE
FACILITY NUMBER: 306005768

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on staff file review, the licensee did not comply with the section cited above as facility staff have not completed eight hours of dementia care training, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, which poses a potential health and safety risk to persons in care.
POC Due Date: 06/28/2024
Plan of Correction
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AD stated remaining required annual staff training would begin to be completed immediately. AD stated they will submit proof to LPA via email by POC date.
Type B
Section Cited
HSC
1569.69(a)(2)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as staff's 6 hours of hands-on shadowing training is not documented, which poses a potential health and safety risk to persons in care.
POC Due Date: 06/14/2024
Plan of Correction
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AD stated 10 of hours of instructional and hands-on shadowing training will be completed and documented and proof will be submitted to LPA via email.
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:Armando J Lucero
LICENSING EVALUATOR NAME:Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 05/30/2024 11:51 AM - It Cannot Be Edited


Created By: Claudia Gutierrez On 05/30/2024 at 11:19 AM
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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SAINT AGNES CARE
FACILITY NUMBER: 306005768

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and staff interview, the licensee did not comply with the section cited above in six out of six medications which poses a potential health and safety risk to persons in care.
POC Due Date: 06/14/2024
Plan of Correction
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AD stated medication would no longer be pre-prepared in advanced and would be maintained in it's original container. AD stated medication storage and management training would be conducted and proof will submitted to LPA via email by POC date.
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:Armando J Lucero
LICENSING EVALUATOR NAME:Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2024


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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SAINT AGNES CARE
FACILITY NUMBER: 306005768
VISIT DATE: 05/30/2024
NARRATIVE
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Staff file review indicated 20 hours of annual staff training has been completed, however, did not contain eight hours of dementia care training, and four hours of which shall be specific to postural supports, restricted health, and hospice. LPA interviewed three residents and two staff.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights was left at the facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024
LIC809 (FAS) - (06/04)
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