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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608255
Report Date: 05/17/2021
Date Signed: 05/17/2021 03:07:30 PM

Document Has Been Signed on 05/17/2021 03:07 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:SAN ANTONIO RESIDENTIAL FACILITYFACILITY NUMBER:
197608255
ADMINISTRATOR:FRANCIS SORIANOFACILITY TYPE:
740
ADDRESS:3013 S. VICTORIA AVENUETELEPHONE:
(323) 733-2835
CITY:LOS ANGELESSTATE: CAZIP CODE:
90016
CAPACITY: 6CENSUS: 4DATE:
05/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Milagros Soriano, Administrator TIME COMPLETED:
03:20 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Jennifer Jones and Troy Agard conducted an unannounced visit to San Antonio Residential Facility. The purpose of today’s visit was to conduct the annual inspection. LPAs was greeted by caregiver Maria Alindayu and later met with administrator, Francis Soriano and Mailgros Soriano. Licensee prefers to serve clients 60 and above. All 3 clients bedrooms are fired cleared for 6 non-ambulatory residents. No hospice waiver. No dementia plan of operation. The facility handles any of the residents’ money.

LPAs and staff toured the physical plant, checked food service, medications, reviewed staff records and reviewed resident files for medical status and first aid kit. The home consists of 3 resident bedrooms, 1 staff bedroom, 1 resident bathroom, 1 staff bathroom, living room/ dining room, and kitchen. LPAs inspected resident bedroom furniture, bed linens and closet/drawer space to accommodate each resident. Resident bathroom were checked. LPAs inspected the toilet and water faucet, grab bars, shower and a non-skid mat was in place. LPAs measured water at 120 degrees. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked under the sink and in the detached garage.

Kitchen was checked and observed. Perishable and non-perishable food supply was checked. Cleaning solutions, hazardous items, and medications were observed. Smoke detectors were working properly and fire extinguisher was fully charged. Carbon monoxide detector was operational. Outside grounds were toured. No body of water observed. Walkways around the home were observed. There are no security bars or weapons on the premises.

The following deficiencies were observed during the inspection:

During the tour, LPAs observed the resident records, staff records, medication, cleaning solutions and knives unlocked and accessible to residents in care.

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Jennifer Jones
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2021
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SAN ANTONIO RESIDENTIAL FACILITY
FACILITY NUMBER: 197608255
VISIT DATE: 05/17/2021
NARRATIVE
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LPAs observed a mattress and folding bed in the hallway off the dining room area leading to a storage closet and another mattress in the kitchen next to the refrigerator. LPAs observed a missing toilet seat cover in residents bathroom.
LPAs observed missing sheets on two beds in bedrooms 1 and 2.
LPAs observed a missing medication administration record sheet for resident 1
LPAs observed paint, bed frame and other miscellaneous items on the patio furniture and surrounding area. LPAs observed boxed closet door located in room 2 located behind resident entry/exit door.
LPAs observed an unlocked broken file cabinet in the dining area with staff and resident records.
LPAs observed residents medication (Milk of Magnesia) in a file cabinet in dining room unlocked and accessible to residents in care.
LPAs observed staff medication (vitamins and other misc meds) in a cabinet unlocked and accessible to residents in care.
LPAs observed cobb webs in resident room 3, clutter in resident room 1, used towels laying on the kitchen and bathroom floor.

(Advisory notes)
Facility will ensure that covid screening is conducted for all visitors upon entry.
Facility will ensure that all staff and resident records are up to date (physicals and IPPs)
Facility will ensure that staff wear mask at all times.
LPAs recommend replacing skid mat in the resident bathroom.

Deficiencies cited on 809 D

Exit interview conducted and a copy of the report was furnished.

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Jennifer Jones
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2021
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 05/17/2021 03:07 PM - It Cannot Be Edited


Created By: Jennifer Jones On 05/17/2021 at 02:14 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
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SAN ANTONIO RESIDENTIAL FACILITY
FACILITY NUMBER: 197608255

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)(1)
Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply:There shall be common rooms such as living rooms, dining rooms, dens or other recreation/activity rooms. They shall be of sufficient space and/or separation to promote and facilitate the program of activities and to prevent such activities from interfering with other functions.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.LPAs observed a mattress and folding bed in the hallway off the dining room area leading to a storage closet. LPAs observed another mattress in the kitchen next to the refrigerator. Staff told LPAs they sleep in the living area to listen for residents in care.

POC Due Date: 05/24/2021
Plan of Correction
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Common areas are not to be used as sleeping quarters by staff or residents. Licensee will submit a LIC 500 showing 24 coverage and will ensure awake staff are awake and performing duties. The administrator will submit POC by POC dute date.
Type B
Section Cited
CCR
87307(a)(3)(C)

Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. … Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. …


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. During the tour, LPAs observed missing sheets on two beds in bedrooms 1 and 2.
POC Due Date: 05/24/2021
Plan of Correction
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The administrator will ensure that all residents beds have the complete bedding which includes comforter, fitted top and bottom sheet, mattress cover and pillows. The administrator will provide proof by POC dute 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:Angela J Kendrick
LICENSING EVALUATOR NAME:Jennifer Jones
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2021


LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 05/17/2021 03:07 PM - It Cannot Be Edited


Created By: Jennifer Jones On 05/17/2021 at 01:48 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
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SAN ANTONIO RESIDENTIAL FACILITY
FACILITY NUMBER: 197608255

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(d)(1)(H)
Resident Records All resident records shall be available... ...records for current residents unless the same information is otherwise readily available in another document or format: Records of current medications.



This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care. LPAs observed a missing medication administration record sheet for resident 1
POC Due Date: 05/24/2021
Plan of Correction
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The administrator will ensure that staff document all medication given in the morning and evening for all residents in care. The administrator will submit the plan by POC due date.
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.LPAs observed paint, bed frame and other miscellaneous items on the patio furniture and surrounding area. LPAs observed boxed closet door located in room 2 located behind resident entry/exit door. LPAs observed an unlocked broken file cabinet in the dining area with staff and resident records. LPAs observed cob webs in resident room 3, clutter in resident room 1, used towels laying on the kitchen and bathroom floor. LPAs observed a missing toilet seat cover in residents’ bathroom.

POC Due Date: 05/24/2021
Plan of Correction
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The administrator will removed and clean back yard area, removed boxed closet door out of resident 1 bedroom, replace file cabinet in dining area, clean cob webs in resident rooms, clean kitchen and bathrooms floors and repair toilet seat by adding a toilet lid.
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:Angela J Kendrick
LICENSING EVALUATOR NAME:Jennifer Jones
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2021


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 05/17/2021 03:07 PM - It Cannot Be Edited


Created By: Jennifer Jones On 05/17/2021 at 01:13 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
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SAN ANTONIO RESIDENTIAL FACILITY
FACILITY NUMBER: 197608255

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)(1)
Storage Space
Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. Storage areas for poisons, and firearms and other dangerous weapons shall be locked.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPAs observed cleaning solutions and knives unlocked and accessible to residents in care.
POC Due Date: 05/18/2021
Plan of Correction
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The administrator will conduct an in-service training on the importance of keeping all hazardous and dangerous items locked and inaccessible residents in care. The administrator will submit documentation by POC due date.
Type A
Section Cited
CCR
87465(h)(2)
Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. During the tour, LPAs observed residents medication (Milk of Magnesia) in a file cabinet in dining room unlocked and accessible to residents in care. LPAs observed staff medication (vitamins and other misc meds) in a cabinet unlocked and accessible to residents in care.
POC Due Date: 05/18/2021
Plan of Correction
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The administrator will conduct an in-service training for staff on the importance of keeping all medication locked an inaccessible to residents in care. The administrator will submit documentation by POC due 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:Angela J Kendrick
LICENSING EVALUATOR NAME:Jennifer Jones
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2021


LIC809 (FAS) - (06/04)
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