421702445-5-21-2024-29-AS-MRAN-D5H2LS-20240521173000

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 421702445
Report Date: 05/21/2024
Date Signed: 05/21/2024 05:30:40 PM

Document Has Been Signed on 05/21/2024 05:30 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	SAN ANTONIO RESIDENCE		FACILITY NUMBER:	421702445
ADMINISTRATOR/ DIRECTOR:	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: 5	DATE:	05/21/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:15 PM
MET WITH:	Administrator Helen San Antonio		TIME VISIT/ INSPECTION COMPLETED:	04:15 PM

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At 12:15 pm on 05/21/2024, Licensing Program Analyst (LPA) Melisa Rankin and Mark Jeffries arrived unannounced to the facility to conduct the annual facility inspection. LPA met with Administrator Helen San Antonio, announced who they were and 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 observed to have 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 locked 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 covered with a desk and is inaccessible. Smoke detector(s) and carbon monoxide detector were tested and were operational at the time of the visit. The LPAs observed required postings throughout the common space. The fire extinguisher was charged and serviced 12/20/2023.

The backyard has a covered outdoor area 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.

Continued on 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SAN ANTONIO RESIDENCE	FACILITY NUMBER: 421702445
	VISIT DATE: 05/21/2024

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Bedrooms: There are three (3) client rooms, with double client occupancy, 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 five (5) 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.

The LPAs reviewed four (4) 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 3/1/2024.

Medications: Medications reviewed, and a sample audit was done. Reviewed all centrally stored medication records. Medications are locked in a cabinet in the dining room.

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.

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

80087(a)(1) – The licensee shall take measures to keep the facility free of flies and other insects.

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

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/21/2024 05:30 PM - It Cannot Be Edited

Created By: Melisa Rankin On 05/21/2024 at 03:42 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: 05/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)(1)

Building and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (1) The licensee shall take measures to keep the facility free of flies and other insects. 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 in that insects, flies and cobwebs were observed and present in the backyard, rear exit and back staff room, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/04/2024
	Plan of Correction
1 2 3 4	Administrator agrees to hire a professional pest control service to do a minimal of one service to midigate spider and flies observed. Administrator agrees to provide receipt of services rendered. Administrator will email reciept to LPA (Melisa.Rankin@dss.ca.gov) by 06/04/24.

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:

Melisa Rankin

LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

LIC809 (FAS) - (06/04)

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