421702445-3-29-2023-29-AS-JOLN-CQDULW-20230329154124

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 421702445
Report Date: 03/29/2023
Date Signed: 03/29/2023 03:42:02 PM

Document Has Been Signed on 03/29/2023 03:42 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	SAN ANTONIO RESIDENCE		FACILITY NUMBER:	421702445
ADMINISTRATOR:	SAN ANTONIO, HELEN S		FACILITY TYPE:	735
ADDRESS:	620 WEST POLK STREET		TELEPHONE:	(805) 928-4989
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93454
CAPACITY: 6		CENSUS: 4	DATE:	03/29/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Helen San Antonio, Administrator/Licensee		TIME COMPLETED:	04:15 PM

NARRATIVE

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Licensing Program Analysts (LPAs) Jenny Olson and Brian Phillips arrived unannounced to conduct a one year required annual. The LPAs met with Licensee/Administrator Helen San Antonio and explained the reason for the visit.

The LPAs toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Kitchen: The kitchen area was observed at 12:10 p.m. The facility has a sufficient supply of non-perishable and perishable food items. Cleaning supplies and disinfectants are stored under the sink, inaccessible to clients. Knives are stored in a cabinet in the kitchen.

Common areas: Living and dining room furniture were observed to be in good condition. There is a fireplace in the living room, which is screened and inaccessible. At 2:15 p.m., smoke detector(s) and carbon monoxide detector were tested and 4 were operational at the time of the visit. The LPAs observed required postings throughout the common space. The fire extinguisher was charged and serviced 12/20/2022.

The backyard has a covered outdoor area equipped with furniture for client use. No bodies of water noted. The washer and dryer are in the garage. The garage is not locked.

Restrooms: The two client restrooms were clean and sanitary and in operating condition with non-skid surfaces. The bathrooms were sufficiently stocked with soap and paper towels. Around 1:00 p.m., the hot water temperature measured in the client restrooms at 110 degrees Fahrenheit.

Bedrooms: There are three (3) client rooms, which were furnished with appropriate linens and required furniture. A linen closet was located outside of the rooms, which stocked extra linens and towels.

Records: The LPAs reviewed client and staff records at 11:00 a.m. The LPAs reviewed four (4) client files for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, and current needs and services plan. All files were complete. Continued on 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SAN ANTONIO RESIDENCE	FACILITY NUMBER: 421702445
	VISIT DATE: 03/29/2023

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The LPAs reviewed five (5) staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, current first aid certification. All files were complete.

The facility is vendored by Tri-Counties Regional Center (TCRC) as a level 2 home. The last disaster drill was conducted on 1/1/2023.

Medications: Medications review began at 11:30 a.m.; medications are centrally stored and locked in a cabinet in the dining room. Medications are labeled and checked for expiration dates. The LPAs advised the Administrator to ensure that all the necessary information is properly documented on the MAR.

Infection Control: The facility has an infection control plan The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol needs to be improved.. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

Around 12:05 p.m. LPA Olson observed cleaning solution under the sink

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).

Exit interview conducted. A copy of the report and appeal rights was printed.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/29/2023 03:42 PM - It Cannot Be Edited

Created By: Jeannette Olson On 03/29/2023 at 03:29 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SAN ANTONIO RESIDENCE	FACILITY NUMBER: 421702445
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(g)

Building and Grounds

(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above when cleaning solutions were left under the sink unlocked in client's bathroom, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/05/2023
	Plan of Correction
1 2 3 4	Administrator agreed to train staff on importance of locking cleaning solutions and submit training with name, date, topic trained, and signatures to LPA Olson by 4/5/23

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Kelly Burley

LICENSING EVALUATOR NAME:

Jeannette Olson

LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023

LIC809 (FAS) - (06/04)

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