<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608255
Report Date: 05/20/2024
Date Signed: 05/20/2024 02:18:03 PM

Document Has Been Signed on 05/20/2024 02:18 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:SAN ANTONIO RESIDENTIAL FACILITYFACILITY NUMBER:
197608255
ADMINISTRATOR/
DIRECTOR:		FRANCIS SORIANOFACILITY TYPE:
740
ADDRESS:3013 S. VICTORIA AVENUETELEPHONE:
(323) 733-2835
CITY:LOS ANGELESSTATE: CAZIP CODE:
90016
CAPACITY: 6CENSUS: 2DATE:
05/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Milagros SorianoTIME VISIT/
INSPECTION COMPLETED:
02:20 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 5/20/24 Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced annual inspection visit to the above facility using the CARE tool. LPA was met by Milagros Soriano, Administrator, and the purpose of today’s visit was explained. The facility is licensed to serve six (6) residents aged 60 and above. All three client bedrooms are fire cleared for six (6) non-ambulatory residents. No hospice waiver. No dementia plan of operation.

The facility is a single-story home located in a residential neighborhood. It consists of three (3) resident bedrooms, of which only two (2) are being used by residents, and one (1) staff bedroom, two (2) bathrooms, living room, dining room, kitchen, laundry area, kitchen, and a detached garage used for storage.

LPA Gonzalez and Milagros Soriano toured the physical plant. There were no bodies of water or obstructions on the premises. All resident rooms were inspected. Bedrooms had the required furniture and in good condition, bed linens and closet/drawer space to accommodate each client comfortably. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were clean and operational and found to be within Title 22 regulations. The water temperature properly measured between 105.0 F and 120.0 F. LPA observed the facility to be clean and appropriately furnished with clear passageways. A comfortable temperature was maintained in the facility.

The kitchen was inspected and there is sufficient perishable and non-perishable food supply and maintained adequately. Sharps, toxins, cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. A landline was observed. Exits/ Walkways around the facility were free of debris and hazards. Smoke detectors and carbon monoxide were tested and are working properly. Fire extinguishers were fully charged. A stocked First Aid kit along with manual was available.

Continued on LIC809-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE: DATE: 05/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: SAN ANTONIO RESIDENTIAL FACILITY
FACILITY NUMBER: 197608255
VISIT DATE: 05/20/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents. There are sanitizing stations in common areas and restrooms. All mandated inspection control posters were posted.

During this inspection LPA did not observe any deficiencies, therefore no citations were issued at this time.

An exit interview was conducted, and a copy of the report and Appeal Rights was emailed to Administrator, Milagros Soriano.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2