198601983-8-4-2022-11-AS-DSEA-CGZ7PQ-20220804215041

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601983
Report Date: 08/04/2022
Date Signed: 08/04/2022 09:50:58 PM

Document Has Been Signed on 08/04/2022 09:50 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:	ST ANTHONY'S CARE HOME II		FACILITY NUMBER:	198601983
ADMINISTRATOR:	SOLETA,BEULAH		FACILITY TYPE:	740
ADDRESS:	1724 W 254TH STREET		TELEPHONE:	(310) 530-9842
CITY:	LOMITA	STATE: CA	ZIP CODE:	90717
CAPACITY: 6		CENSUS: 5	DATE:	08/04/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:51 PM
MET WITH:	Myrna Dennis and Nestor Villena - both caregivers		TIME COMPLETED:	03:45 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 08/04/2022, Licensing Program Analyst (LPA) Don Senaha conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA was met by caregiver Myrna Dennis and Nestor Villena and was later joined by Administrator Kenneth Soleta and explained the purpose of today’s visit. The facility is licensed to serve six (6) elderly residents ages 60 and above.. The facility has a hospice waiver for two (2) residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: six (6) resident's rooms, two (2) staff rooms, three (3) bathrooms, living area, dining area, kitchen, and outside shaded patio area covered with a canopy and ample seating in backyard. All five (5) residents were in the facility at the time of the visit. LPA and caregivers Myrna Dennis and Nestor Villena toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident personal belongings was observed. 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 operational. The water temperature did not meet Title 22 regulations and are cited on the D page. There is a car port located at the rear of the house and is accessible through the alley in the back yard which is gated. There is also a second freezer located in the staff room for extra frozen food. Evaluation Report Continues on LIC 809-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022

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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Document Has Been Signed on 08/04/2022 09:50 PM - It Cannot Be Edited

Created By: Don Senaha On 08/04/2022 at 03:13 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: ST ANTHONY'S CARE HOME II	FACILITY NUMBER: 198601983
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). 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. The water temperature in the bathrooms and kitchen sinks measured beetween 138.1 F and 146.8 F, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/05/2022
	Plan of Correction
1 2 3 4	Administrator to send pictures of temperature for each bathroom and kitchen sink.

Type A

Section Cited

CCR

87705(f)(1)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). 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. Under the kitchen sink there was an unlocked knife which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/05/2022
	Plan of Correction
1 2 3 4	Caregiver immediately removed and locked the knife .

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:

Eva M Alvarez

LICENSING EVALUATOR NAME:

Don Senaha

LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022

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: ST ANTHONY'S CARE HOME II	FACILITY NUMBER: 198601983
	VISIT DATE: 08/04/2022

NARRATIVE

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LPA observed the facility to be appropriately furnished at the time of visit. LPA observed cleaning supplies and toxins not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available and properly maintained. There are two (2) fire extinguishers fully charged in the kitchen area. Smoke detectors and carbon monoxide were tested and operational. A review of Medication Administration Records (MAR) was maintained in order and accurate. There was a first aid kit available stored in the kitchen.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed all mandated inspection control posters were posted.

Advisory Notes – Three (3) Technical Assistance were issued, please see LIC9102-AN.

There were two deficiencies cited during this inspection visit. See 809D page.

An exit interview was conducted and a copy of this report was provided to Administrator Kenneth Soleta.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022

LIC809 (FAS) - (06/04)

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