374603148-9-25-2024-08-AS-DNGN-D9FRBW-20240925125324

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603148
Report Date: 09/25/2024
Date Signed: 09/25/2024 12:53:55 PM

Document Has Been Signed on 09/25/2024 12:53 PM - 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	ANTONIO'S BOARD AND CARE		FACILITY NUMBER:	374603148
ADMINISTRATOR/ DIRECTOR:	DULCE P. ANTONIO		FACILITY TYPE:	735
ADDRESS:	3737 FESTIVAL CT		TELEPHONE:	(619) 271-8329
CITY:	CHULA VISTA	STATE: CA	ZIP CODE:	91911
CAPACITY: 4		CENSUS: 4	DATE:	09/25/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:20 AM
MET WITH:	Licensee Dulce Antonio and Manager Jerijan Antonio		TIME VISIT/ INSPECTION COMPLETED:	01:00 PM

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	Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced visit to conduct a Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Licensee Dulce Antonio. LPA also met with Manager Jerijan Antonio, who arrived later during the visit. According to the facility’s license, the facility has a maximum capacity of four (4) clients, of whom all must be ambulatory. Per LIC602 Physician’s Reports and staff interviews: During today’s inspection, there were a total of four (4) clients in care, and all were ambulatory. The facility’s license does not include endorsements for delayed-egress doors or secured perimeter, and none of these were present. During today’s visit, the clients were all away at off-site day programs. However, LPA interviewed multiple staff and reviewed records for all clients and staff. LPA, accompanied by the Licensee, also toured the interior and exterior of the facility, and inspected all common areas and resident bedrooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were working. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was complaint at 77 F. Hot water temperature at taps accessible to clients were all compliant: Bathroom #1 Sink was 108.6 F and Bathroom #2 Sink was 109.6 F. Appliances to preserve perishable food were also all compliant in temperature: Refrigerators were 38 F and 39 F, respectively. Freezers were -7 F, -5 F, and 0 F, respectively. There was at least two (2) days of perishable food, and at least seven (7) days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. [CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024

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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Document Has Been Signed on 09/25/2024 12:53 PM - It Cannot Be Edited

Created By: Dang Nguyen On 09/25/2024 at 11:49 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ANTONIO'S BOARD AND CARE	FACILITY NUMBER: 374603148
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85095.5(b)(2)(C)

Infection Control Requirements

(b) In addition to subsection (a), when one or more clients in the facility are diagnosed with a contagious disease, the following shall apply: (2) All staff and volunteers providing direct care to a client who has a contagious disease shall wear appropriate Personal Protective Equipment (PPE) to prevent exposure to infectious agents or chemicals through the respiratory system, skin, or mucous membranes of the eyes, nose, or mouth. PPE may include gloves, gowns, masks, respirators, shoe coverings and eye protection. (C) The licensee shall ensure all staff and volunteers are trained in the proper use of all required PPE prior to being around clients and annually thereafter. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	This requirement was not met, as evidenced by: Based on records review and interviews, Licensee did not ensure that 4 of 4 staff (S1 through S4) were trained in the proper use of all required PPE, annually. This posed a potential health risks to persons in care.
	POC Due Date: 10/25/2024
	Plan of Correction
1 2 3 4	Licensee agreed to retrain S1 through S4 on how to correctly don and doff surgical masks, N-95 respirators, face shields, gowns, and gloves, and how to perform an N-95 seal check. The training will be in person and include both videos and hands-on practice with PPE. Licensee agreed to E-mail a copy of the training sign-in sheet to LPA, by the POC due date. Going forward, Licensee agreed to repeat this training at least once per year.

Type B

Section Cited

HSC

1565(b)

HSC 1565: “(b) If a facility employs staff, the facility shall provide training on the plan to each staff member upon hire and annually thereafter. The training shall include staff responsibilities during an emergency or disaster.” This requirement was not met, as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review and interviews, Licensee did not ensure that 4 of 4 staff (S1 through S4) received training on the facility’s emergency and disaster plan (to include staff responsibilities under the plan) annually. This posed a potential safety risk to clients in care.
	POC Due Date: 10/25/2024
	Plan of Correction
1 2 3 4	Licensee agreed to retrain S1 through S4 on the facility’s existing LIC610D Emergency and Disaster Plan and their responsibilities under it. Licensee agreed to E-mail a copy of the training sign-in sheet to LPA, by the POC due date. Going forward, Licensee agreed to repeat this training at least once per year.

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:

Lizzette Tellez

LICENSING EVALUATOR NAME:

Dang Nguyen

LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024

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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ANTONIO'S BOARD AND CARE	FACILITY NUMBER: 374603148
	VISIT DATE: 09/25/2024

NARRATIVE

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[CONTINUED FROM LIC 809]

There were no sharp objects, toxic chemicals/poisons, active fireplaces, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas. Confidential records were stored in locked areas. No pools or bodies of water were observed on the premises. Per the Licensee, no firearms or ammunition are kept at the facility.

Fire detection system, carbon monoxide detector, night lights, emergency lighting, and facility telephone were all working. The facility’s fire extinguisher was serviced within the last twelve (12) months. Required licensing postings were observed in visible areas of the facility. Fire/disaster drills were performed at required intervals. Reserve supplies of Personal Protective Equipment (PPE) were on site. Licensee presented proof of current business liability insurance.

During review of training records, LPA observed, and manager interviews confirmed: 4 of 4 facility staff [Staff #1 (S1), Staff #2 (S2), Staff #3 (S3), and Staff #4 (S4)] had not received training on PPE within the last year, as required. S1, S2, S3, and S4 also had not received training on the facility’s written Emergency and Disaster Plan within the last year, as required. [See LIC811 Confidential Names List for a description of person identifiers used.]

One (1) deficiency was cited per California Code of Regulations, Title 22, and one (1) deficiency was cited per California Health and Safety Code (refer to the attached LIC 809-D page). Plans of Correction were jointly developed with the Licensee. LPA also issued one (1) Technical Violation (TV) regarding a personnel file for S4 (see the LIC 9102-TV page).

An exit interview was conducted with Dulce Antonio. A copy of this report, the LIC 809-D page, the LIC 9102-TV page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided to Licensee during today's visit.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024

LIC809 (FAS) - (06/04)

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