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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005768
Report Date: 02/25/2025
Date Signed: 02/25/2025 11:18:33 AM

Document Has Been Signed on 02/25/2025 11:18 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:
02/25/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:John Paul "JP" Vargas
Lester Del Rosario		TIME VISIT/
INSPECTION COMPLETED:
11:35 AM
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 Staff JP Vargas. Administrator (AD) Lester Del Rosario arrived at approximately 8:50 a.m. and the purpose of the inspection was discussed.

During the inspection, LPA and AD 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. The first story consists of six resident bedrooms, one staff bedroom, three bathrooms, and attached two-car garage. 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, and faucets and toilets were operational. Water temperature tested between 113.5-113.7 degrees Fahrenheit. 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. Fire extinguisher was observed to be fully charged with a service tag dated March 5, 2024. Electric stove, microwave, washer, and dryer were all inspected and observed to be operable. Toxic chemicals, cleaning solutions, and disinfectants were observed to be inaccessible to residents. Medication was observed to be centrally stored in a locked cabinet.

LPA reviewed five resident files and three staff files. Three of five resident files did not have a re-appraisal dated or signed in the last twelve months and two of five resident medical assessments did not include results of examination for TB. LPA interviewed four residents and two staff.

Based on the observations made during today’s inspection, two 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: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2025
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 02/25/2025 11:18 AM - It Cannot Be Edited


Created By: Claudia Gutierrez On 02/25/2025 at 10:33 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: 02/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(c)(1)(A)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis.

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 two of five resident medical assessments did not include results of examination for TB, which poses a potential health risk to persons in care.
POC Due Date: 03/11/2025
Plan of Correction
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AD stated TB examination results will be obtained and proof provided via email by POC date.
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

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 in three of five resident files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/11/2025
Plan of Correction
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AD stated appraisals will be completed, signed, and dated for residents and proof provided to LPA via email by 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:Armando J Lucero
LICENSING EVALUATOR NAME:Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2025


LIC809 (FAS) - (06/04)
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