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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 421702445
Report Date: 08/01/2024
Date Signed: 08/01/2024 01:16:48 PM

Document Has Been Signed on 08/01/2024 01:16 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 RESIDENCEFACILITY NUMBER:
421702445
ADMINISTRATOR/
DIRECTOR:
SAN ANTONIO, HELEN SFACILITY TYPE:
735
ADDRESS:620 WEST POLK STREETTELEPHONE:
(805) 928-4989
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY: 6CENSUS: 5DATE:
08/01/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Jonelyn San Antonio - Alternate AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:59 PM
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At 10:00am on 08/01/2024, Licensing Program Analyst (LPA) Jeffries and Tri Counties Regional Center (TCRC) Quality Assurance Specialist Vince Figuaroa (QA) arrived unannounced to the facility to conduct the initial investigation visit to the allegations on a separate complaint. Upon facility tour for the separate complaint visit, LPA discovered issues below that will be addressed on a this Case Management visit. QA and LPA met with Alternate Administrator Jonelyn San Antonio, announced the reason for the visit and who LPA and QA.
LPA during a facility tour found the bathroom number one to have been recently under construction. LPA noted that the construction has not been completed and the boarders surrounding the shower insert have exposed nail heads and missing dry wall around the boarder of the shower insert and under the commode. There is also an exposed, rusted nail in the wall over the commode. LPA noted that this puts the facility in disrepair. Mrs. San Antonio agreed to have a local contractor to be scheduled by Monday August 5, 2024 before close of business. This construction should be completed no more than 2 weeks from scheduling with contractor. Mrs.San Antonio will follow up with LPA on 08/05/2024, additionally, with start and completion of repairs to the bathroom.

QA and LPA also discovered that Care Staff 1 (S1) has recently had a heart monitor placed due to a recent decline in health condition. QA and LPA required S1 to have S1 present a medical clearance by a licensed physician to work with clients in care. S1 is not to be alone with clients until they are cleared by physician. Mrs.San Antonio will contact LPA and QA as soon as S1 has been cleared by a physician.

Exit interview, report read, and report provided.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/01/2024
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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