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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
019201080
Report Date:
01/26/2024
Date Signed:
01/27/2024 11:52:13 AM
Document Has Been Signed on
01/27/2024 11:52 AM
- 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
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
ST. ANTHONY'S RESIDENTIAL CARE HOME
FACILITY NUMBER:
019201080
ADMINISTRATOR:
WILSON, JOSEPHINE B.
FACILITY TYPE:
740
ADDRESS:
2661 LAKEVIEW DR.
TELEPHONE:
(510) 908-1027
CITY:
SAN LEANDRO
STATE:
CA
ZIP CODE:
94577
CAPACITY:
6
CENSUS:
5
DATE:
01/26/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
09:30 AM
MET WITH:
BOOTSANSON FLORES CAREGIVER
TIME COMPLETED:
03:15 PM
NARRATIVE
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On 1/26/2024 at 9:30am, Licensing Program Analysts (LPAs) Carol Fowler and Tonica Syess-Gibson conducted an unannounced 1-Year Required inspection. LPAs met with
Bootsanson Flores, Caregiver, and
explained the purpose of the visit. Chris Wilson, Facility Manager arrived at 11:15am. The Administrator currently holds a certificate (#6036411740) that expired on 08/14/2023 which is in the process of being renewed. The facility’s fire clearance was approved for six (6) ambulatory residents.
LPA toured the facility with Caregiver including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of six (6) total bedrooms, and three (3) bathrooms. A comfortable temperature is maintained at 70 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 109.1 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars.
Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was missing service tag. Emergency Disaster Plan was posted. First aid kit was observed to be complete.
Facility did not have staff files available for review and resident files were all incomplete.
Continued on LIC809C.
SUPERVISOR'S NAME:
Bennett Fong
TELEPHONE:
(510) -62-2621
LICENSING EVALUATOR NAME:
Carol Fowler
TELEPHONE:
(510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE:
01/26/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/26/2024
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
18
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
ST. ANTHONY'S RESIDENTIAL CARE HOME
FACILITY NUMBER:
019201080
VISIT DATE:
01/26/2024
NARRATIVE
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LPA observed the following deficiencies:
·
At 9:50am, LPAs observed Refrigerator leaking and seal in the freezer area lose.
·
At 9:56am, LPAs observed scissors on the kitchen counter.
·
At 9:58am, LPAs observed a knife block with 11 knives and 1 pair of scissors on the kitchen counter.
·
At 9:59am, LPAs hardwood floor cleaner, syringes, glass cleaner underneath the kitchen sink unlocked.
·
At 10:03am, LPAs observed medication in an unlocked drawer in the kitchen, goof off and a knife.
·
At 10:06am, LPAs observed medication cabinet unlocked with bottles of vitamins and medication, which also had a lighter.
·
At 10:08am, LPAs observed Fire Extinguisher was not tagged with service tag.
·
At 10:09am, LPAs observed paint, poly stain in a unlocked cabinet and fire place prong on the fire place in a common family room.
·
At 10:10am, LPAs observed 2 drills, cough medication, centrally stored medications in an unlocked cabinet, Lysol, resolve air freshener all located in an unlocked office.
·
At 10:14am, LPAs observed scissors and medication (ointment) unlocked in located in resident room #2.
·
At 10:15am, LPAs observed ointment and eye drops in resident room #3.
·
At 10:22am, LPAs observed unlocked laundry room door with Lysol, Ajax, Clorox wipes, laundry detergent and fabric softener in an unlocked cabinet.
·
At 10:27am, LPAs observed wire cutters, eye drops, and a knife in room #6.
·
At 10:30am, LPAs observed bathtub and shower floor with stains.
Continued on LIC809C.
SUPERVISOR'S NAME:
Bennett Fong
TELEPHONE:
(510) -62-2621
LICENSING EVALUATOR NAME:
Carol Fowler
TELEPHONE:
(510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE:
01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/26/2024
LIC809
(FAS) - (06/04)
Page:
2
of
18
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
ST. ANTHONY'S RESIDENTIAL CARE HOME
FACILITY NUMBER:
019201080
VISIT DATE:
01/26/2024
NARRATIVE
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Continued from LIC809C.
·
At 10:36am, LPAs observed unlocked shed on the side yard with paint and power tools.
·
At 10:37am, LPAs observed damaged window screens in the side/back yard.
·
At 10:38am, LPAs observed unlocked swimming pool gate.
·
At 10:39am, LPAs observed a chain saw, paint and a ladder on the side yard located on a table.
·
At 10:40am, LPAs observed a shed being used as living quarters for staff in the back yard.
·
At 11:06am, LPAs during record review observed facility Manager not associated to the facility.
·
At 11:09am, LPAs observed resident records are incomplete.
·
At 11:10am, LPAs during record review observed staff files not available for review.
·
At 11:17am, LPAs during record review observed emergency disaster drill documents not available.
·
At 11:58am, LPAs observed an odor in the garage.
·
At 12:05am, LPAs observed a knife located in the china cabinet in the dining area.
LPA requested the following documents to be submitted to CCLD by 2/09/2024.
·
Resident Roster
·
LIC 308 Designation of Administrative Responsibility
·
LIC 309 Administrative Organization
·
LIC 500 Personnel Report
·
LIC 610E Emergency Disaster Plan (9 pages)
·
Liability Insurance
continue on LIC 809C
SUPERVISOR'S NAME:
Bennett Fong
TELEPHONE:
(510) -62-2621
LICENSING EVALUATOR NAME:
Carol Fowler
TELEPHONE:
(510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE:
01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/26/2024
LIC809
(FAS) - (06/04)
Page:
4
of
18
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
ST. ANTHONY'S RESIDENTIAL CARE HOME
FACILITY NUMBER:
019201080
VISIT DATE:
01/26/2024
NARRATIVE
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3
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5
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continue from LIC 809C
The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.
Exit interview conducted. Annual Inspection will be continued at a later date.
SUPERVISOR'S NAME:
Bennett Fong
TELEPHONE:
(510) -62-2621
LICENSING EVALUATOR NAME:
Carol Fowler
TELEPHONE:
(510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE:
01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/26/2024
LIC809
(FAS) - (06/04)
Page:
3
of
18
Document Has Been Signed on
01/27/2024 11:52 AM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
ST. ANTHONY'S RESIDENTIAL CARE HOME
FACILITY NUMBER:
019201080
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
01/26/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(f)(2)
Maintenance and Operation
(f) Solid waste shall be stored and disposed of as follows: (2) Syringes and needles are disposed of in accordance with the California Code of Regulations, Title 8, Section 5193 concerning bloodborne pathogens.
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 by having 2 water bottles filled with syringes under the kitchen sink unlocked which poses an immediate health and safety risk to persons in care.
POC Due Date:
01/28/2024
Plan of Correction
1
2
3
4
Administrator agreed to read the regulation and dispose of the syringes according to the CCR Title 8, Section 5193 concerning blood borne pathogens and send self certification to CCL by the POC date. DEFICIENCY CLEARED DURING CONTINUATION VISIT.
Type A
Section Cited
CCR
87307(e)
Personal Accommodations and Services
(e) Facilities providing services to residents who have physical or mental disabilities shall assure the inaccessibility of fishponds, wading pools, hot tubs, swimming pools or similar bodies of water, when not in active use by residents, through fencing, covering or other means.
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 by having the swimming pool unlocked which poses an immediate health and safety risk to persons in care.
POC Due Date:
01/28/2024
Plan of Correction
1
2
3
4
Administrator will read, understand the regulation and conduct an in-service training pertaining to 87307(e) and submit a certificate of completion with log of all staff participants, to CCL by POC date. DEFICIENCY CLEARED DURING CONTINUATION VISIT.
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:
Bennett Fong
TELEPHONE:
(510) -62-2621
LICENSING EVALUATOR NAME:
Carol Fowler
TELEPHONE:
(510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE:
01/26/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/26/2024
LIC809
(FAS) - (06/04)
Page:
5
of
18
Document Has Been Signed on
01/27/2024 11:52 AM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
ST. ANTHONY'S RESIDENTIAL CARE HOME
FACILITY NUMBER:
019201080
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
01/26/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by having disinfectants, cleaning solutions throughout the facility in the kitchen bedrooms, bathrooms laundry room, all unlocked and assesable to residents which poses an immediate health and safety risk to persons in care.
POC Due Date:
01/28/2024
Plan of Correction
1
2
3
4
Administrator/Manager will read and understand regulation conduct an inservice with all staff and submit documents of all attendies to CCL by the POC date. DEFICIENCY CLEARED DURING CONTINUATION VISIT.
Type A
Section Cited
CCR
87309(a)(1)
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. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.
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 by having scissors, hammer, wire cutters, Paint, power tools, chain saw, knives, fire place prongs, poly stain throughout the facility located in the office, sitting room, and dining room which poses an immediate health and safety risk to persons in care.
POC Due Date:
01/28/2024
Plan of Correction
1
2
3
4
Administrator/Manager will read and understand regulation conduct an inservice with all staff and submit documents of all attendies to CCL by the POC date. DEFICIENCY CLEARED DURING CONTINUATION VISIT.
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:
Bennett Fong
TELEPHONE:
(510) -62-2621
LICENSING EVALUATOR NAME:
Carol Fowler
TELEPHONE:
(510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE:
01/26/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/26/2024
LIC809
(FAS) - (06/04)
Page:
6
of
18
Document Has Been Signed on
01/27/2024 11:52 AM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
ST. ANTHONY'S RESIDENTIAL CARE HOME
FACILITY NUMBER:
019201080
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
01/26/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(b)
Storage Space
(b) Medicines shall be stored as specified in Section 87465(c) and separately from other items specified in (a) above.
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 by having medication stored in a cabinet unlocked, medication found in residents rooms, and medication in drawer in the kitchen, medication in an unlocked office which poses an immediate health and safety risk to persons in care.
POC Due Date:
01/28/2024
Plan of Correction
1
2
3
4
Administrator/Manager agreed to read regulation and conduct inservice with all staff handling medication. Remove all medication from unlocked areas such as the unlocked office, medication in drawers in the kitchen, medication in residents rooms and put a lock on the cabinet containing medication submit photos of all medication locked in a locked cabinet by the POC date. DEFICIENCY CLEARED DURING CONTINUATION VISIT.
Type A
Section Cited
CCR
87203
Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
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 by -Fire Extinguisher noted to not have any indication of when last serviced which poses an immediate health and safety or personal rights risk to persons in care.
POC Due Date:
01/28/2024
Plan of Correction
1
2
3
4
Administrator/Manager shall ensure that, facility fire extinguisher is serviced at least annually. This will ensure that fire extinguisher is functioning properly in the event of a fire emergency. Administrator shall have fire extinguisher serviced or purchase a new one and submit proof by POC date. DEFICIENCY CLEARED DURING CONTINUATION VISIT.
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:
Bennett Fong
TELEPHONE:
(510) -62-2621
LICENSING EVALUATOR NAME:
Carol Fowler
TELEPHONE:
(510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE:
01/26/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/26/2024
LIC809
(FAS) - (06/04)
Page:
7
of
18
Document Has Been Signed on
01/27/2024 11:52 AM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
ST. ANTHONY'S RESIDENTIAL CARE HOME
FACILITY NUMBER:
019201080
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
01/26/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above having a leaking refridgrator with the seal on the freezer loose, a freezer located in the garage that needs to be cleaned which poses a potential health and safety risk to persons in care.
POC Due Date:
02/16/2024
Plan of Correction
1
2
3
4
Administrator/Manager agreed to replace broken refridgerator and clean freezer located in the garage and submit photos of the receipt for new refridgerator and cleaned freezer to CCL by POC date.
Type B
Section Cited
CCR
87303(a)(1)
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. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.
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 having stains in the bathtub and shower floors located in bedroom #6 which poses a potential health and safety risk to persons in care.
POC Due Date:
02/16/2024
Plan of Correction
1
2
3
4
Administrator/Manager agreed to clean the bathtub and shower floors and submit photos to CCL by the POC 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:
Bennett Fong
TELEPHONE:
(510) -62-2621
LICENSING EVALUATOR NAME:
Carol Fowler
TELEPHONE:
(510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE:
01/26/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/26/2024
LIC809
(FAS) - (06/04)
Page:
8
of
18
Document Has Been Signed on
01/27/2024 11:52 AM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
ST. ANTHONY'S RESIDENTIAL CARE HOME
FACILITY NUMBER:
019201080
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
01/26/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.
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 by having widow screens maintained which poses a potential health and safety risk to persons in care.
POC Due Date:
02/16/2024
Plan of Correction
1
2
3
4
Administrator/Manager agreed to replace the torn window screens and submit photos to CCL by the POC date.
Type B
Section Cited
CCR
87311
Telephones
All facilities shall have telephone service on the premises. Facilities with a capacity of sixteen (16) or more persons shall be listed in the telephone directory under the name of the facility.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above by not having telephone service at the facility which poses a potential health and safety to persons in care.
POC Due Date:
02/16/2024
Plan of Correction
1
2
3
4
Administrator/Manager agreed to get telephone service at the facility and submit phone number and a copy of the invoice to CCL by the POC 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:
Bennett Fong
TELEPHONE:
(510) -62-2621
LICENSING EVALUATOR NAME:
Carol Fowler
TELEPHONE:
(510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE:
01/26/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/26/2024
LIC809
(FAS) - (06/04)
Page:
9
of
18
Document Has Been Signed on
01/27/2024 11:52 AM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
ST. ANTHONY'S RESIDENTIAL CARE HOME
FACILITY NUMBER:
019201080
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
01/26/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above by not having a staff schedule or LIC 500 or staff documents which poses a potential health and safety risk to persons in care.
POC Due Date:
02/16/2024
Plan of Correction
1
2
3
4
Administrator/Manager agreed to provide a copy of the LIC 500 via email by POC date.
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above by not having a copy of staff CPR documents which poses a potential health and safety risk to persons in care.
POC Due Date:
02/16/2024
Plan of Correction
1
2
3
4
Administrator/Manager agreed to read regulation conduct an inservice training on HSC 1569.618(c)(3). Ensure that 1 staff has CPR and first aid training on duty at all times. Submit a copy of staff CPR/First Aid card and a list of all staff that attended inservice training to CCL by POC 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:
Bennett Fong
TELEPHONE:
(510) -62-2621
LICENSING EVALUATOR NAME:
Carol Fowler
TELEPHONE:
(510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE:
01/26/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/26/2024
LIC809
(FAS) - (06/04)
Page:
10
of
18
Document Has Been Signed on
01/27/2024 11:52 AM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
ST. ANTHONY'S RESIDENTIAL CARE HOME
FACILITY NUMBER:
019201080
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
01/26/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above by not having staff files maintained at the facility which poses a potential health and safety risk to persons in care.
POC Due Date:
02/16/2024
Plan of Correction
1
2
3
4
Administrator/Manager agreed to read regulation and create staff files and submit copies of each staff file to CCL by the POC date
Type B
Section Cited
HSC
1569.267(d)
Resident's Bill of Rights
(d) The licensee shall provide initial and ongoing training for all members of its staff to ensure that residents’ rights are fully respected and implemented.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above by not having any traing documents for staff maintained at the facility which poses a potential health and safety risk to persons in care.
POC Due Date:
02/16/2024
Plan of Correction
1
2
3
4
Administrator/Manager agreed to submit all staff current training to CCL by POC 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:
Bennett Fong
TELEPHONE:
(510) -62-2621
LICENSING EVALUATOR NAME:
Carol Fowler
TELEPHONE:
(510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE:
01/26/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/26/2024
LIC809
(FAS) - (06/04)
Page:
11
of
18
Document Has Been Signed on
01/27/2024 11:52 AM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
ST. ANTHONY'S RESIDENTIAL CARE HOME
FACILITY NUMBER:
019201080
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
01/26/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)
Resident Records
(b) Each resident's record shall contain at least the following information:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above by having incomplete resident files which poses a potential health and safety risk to persons in care.
POC Due Date:
02/16/2024
Plan of Correction
1
2
3
4
Administrator/Manager agreed to read regulation and complete resident files and send a copy of all resident files to CCL by POC date.
Type B
Section Cited
HSC
1569.695(a)(1)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (1) Evacuation procedures, including identification of an assembly point or points that shall be included in the facility sketch.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above by not having a current emergency and disaster plan at the facility which poses a potential health and safety risk to persons in care.
POC Due Date:
02/16/2024
Plan of Correction
1
2
3
4
Administrator/Manager agreed to complete emergency and disaster plan and evacuation procedure plan and submit a copy to CCL by POC 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:
Bennett Fong
TELEPHONE:
(510) -62-2621
LICENSING EVALUATOR NAME:
Carol Fowler
TELEPHONE:
(510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE:
01/26/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/26/2024
LIC809
(FAS) - (06/04)
Page:
12
of
18
Document Has Been Signed on
01/27/2024 11:52 AM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
ST. ANTHONY'S RESIDENTIAL CARE HOME
FACILITY NUMBER:
019201080
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
01/26/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above by not conducting quarterly drills document which poses a potential health and safety risk to persons in care.
POC Due Date:
02/16/2024
Plan of Correction
1
2
3
4
Administrator/Manager agreed to conduct emergency drills, chart and submit documents to CCL by the POC date.
Type B
Section Cited
CCR
87411(g)
Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: Request a transfer of a criminal record clearance
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above by having staff (facility Manager) working in the facility unassociated which poses a potential health and safety risk to persons in care.
POC Due Date:
01/31/2024
Plan of Correction
1
2
3
4
Administrator shall contact CCL directly to verify any and all staff members have been associated to the facility prior to starting work. Administrator to read, understand, and implement regulatory requirement and self certify understanding and submit to CCL by POC 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:
Bennett Fong
TELEPHONE:
(510) -62-2621
LICENSING EVALUATOR NAME:
Carol Fowler
TELEPHONE:
(510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE:
01/26/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/26/2024
LIC809
(FAS) - (06/04)
Page:
13
of
18
Document Has Been Signed on
01/27/2024 11:52 AM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
ST. ANTHONY'S RESIDENTIAL CARE HOME
FACILITY NUMBER:
019201080
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
01/26/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87208(A)(7)
87208((A) Building(s) to be occupied, including a floor plan that describes the capacities of the buildings for the uses intended...7)Sketches, showing dimensions, of the following:
This requirement was not met as evidence by:
Deficient Practice Statement
1
2
3
4
Based on LPA observation licensee did not comply with the section cited above by staff sleeping in a pool/storage makeshift bedroom being used for accommodation. Which poses a potential health and safety risk to residents.
POC Due Date:
02/16/2024
Plan of Correction
1
2
3
4
Administrator/Manager agreed not to allow staff to sleep in the pool/storage room. Facility will submit a written addendum to their operating plan describing how the pool/storage room will be utilized as intended to CCLD by POC date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:
Bennett Fong
TELEPHONE:
(510) -62-2621
LICENSING EVALUATOR NAME:
Carol Fowler
TELEPHONE:
(510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE:
01/27/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/27/2024
LIC809
(FAS) - (06/04)
Page:
18
of
18