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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608255
Report Date: 11/30/2022
Date Signed: 11/30/2022 02:39:17 PM

Document Has Been Signed on 11/30/2022 02:39 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
EL SEGUNDO, 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: 2DATE:
11/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:58 AM
MET WITH:Mila Soriano and Richard SorianoTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mario Leon conducted an unannounced visit to San Antonio Residential Facility. The purpose of today’s visit was to conduct the annual inspection with a focus on infection control. LPA was met by Mila Soriano and later by Richard Soriano. Licensee prefers to serve clients 60 and above. All 3 client bedrooms are fire cleared for 6 non-ambulatory residents.

There are currently two (2) South Central Regional Center clients in placement. All (2) clients are ambulatory. The facility is a single-story structure located in a residential neighborhood. It consists of the following: Three (3) resident bedrooms, One (1) staff bedroom, one (1) resident bathroom, one (1) staff bathroom, living room / dining room, and kitchen. LPAs inspected resident bedroom furniture, bed linens and closet space to accommodate each resident. Resident bathroom was checked. LPAs inspected the toilet and water faucet, grab bars, shower and a non-skid mat was in place. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked under the sink and in the detached garage.



LPA and administrator toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 115.5 F in the kitchen and 112.6 F in the client's bathroom. A comfortable temperature is maintained in the facility. LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is enough perishable and non-perishable food available which is stored properly. Fire extinguishers were charged, smoke detectors and Carbon Monoxide were operable.

See LIC 809-C
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2022
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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SAN ANTONIO RESIDENTIAL FACILITY
FACILITY NUMBER: 197608255
VISIT DATE: 11/30/2022
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Kitchen was checked and observed. Perishable and non-perishable food supply was checked. Cleaning solutions, hazardous items, and medications were observed, locked away from clients. Outside grounds were toured. No body of water observed. Walkways around the home were observed and clear for any egress. There are no security bars or weapons on the premises.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff and residents, sanitizing stations ( Located in common areas and restrooms). LPA observed staff were wearing face coverings, an isolation room and all required postings were present throughout the facility.

LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licening Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.



During today’s visit there was one deficiency observed, see LIC809-D.

Exit interview held. A copy of the report was provided to Richard Soriano.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/30/2022 02:39 PM - It Cannot Be Edited


Created By: Mario Leon On 11/30/2022 at 02:25 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: 11/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)
Storage Space
(a) 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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the findings of CLR cleaning solutions below the clients' sink, the licensee did not comply with the section cited above in the client's bathroom containing CLR cleaning solution below the sink which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/30/2022
Plan of Correction
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Licensee immediately relocated cleaning solution to below the kitchen sink, inaccessible to clients.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Ulysses Coronel
LICENSING EVALUATOR NAME:Mario Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2022


LIC809 (FAS) - (06/04)
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