374600449-12-7-2023-08-AS-CLOZ-CYB53K-20231207183603

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374600449
Report Date: 12/07/2023
Date Signed: 12/07/2023 06:37:25 PM

Document Has Been Signed on 12/07/2023 06:37 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	ST. ANTHONY'S BOARD AND CARE		FACILITY NUMBER:	374600449
ADMINISTRATOR:	BESSIE PASCUAL		FACILITY TYPE:	740
ADDRESS:	6533 PLAZA RIDGE ROAD		TELEPHONE:	(619) 470-4571
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92114
CAPACITY:	6	CENSUS: 6	DATE:	12/07/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:20 PM
MET WITH:	Bessie Pascual, Licensee		TIME COMPLETED:	06:45 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	Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced required Annual Inspection. The facility file was reviewed prior to the visit. LPA Lopez identified herself, was granted entry by caregiver Nenita Abat. LPA discussed the purpose of the visit with caregiver Abat. Licensee Bessie Pascual later arrived and joined the visit. According to the facility’s license, there may be a maximum of six (6) residents; four (4) whom may be non-ambulatory approved in rooms 1 & 5, and two (2) approved for hospice, in at any given time at the facility site. During today’s inspection, the facility’s current census is 6 residents living at the facility. There were 5 residents present at the facility site during the inspection. The last resident returned from program during the inspection. LPA, accompanied by Licensee Pascual, toured the interior and exterior parts of the facility, and inspected each room. The facility was clean, sanitary and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and activities. The facility’s ambient internal temperature was comfortable and compliant, at 68 degrees Fahrenheit (F). Hot water temperature at taps accessible to residents was not compliant before the visit was concluded: kitchen sink was a high of 135.1 degrees F; sink in restroom #1 delivered hot water at 130.8 degrees F; sink in restroom #2 delivered hot water at 129.6 degrees F. There was at least 2 days of perishable food, and at least 7 days non-perishable food present. Cooking/dining equipment and utensils were present, and all safely stored. There were no toxic chemicals/poisons accessible to residents. Medications were properly labeled, as required, and stored in locked areas. LPA inspected the medication room and found that medications were properly labeled and stored in a locked cabinet. The facility maintained medication logs which LPA reviewed. [CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Carmen Lopez	TELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ST. ANTHONY'S BOARD AND CARE	FACILITY NUMBER: 374600449
	VISIT DATE: 12/07/2023

NARRATIVE

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[CONTINUED FROM LIC 809]

No pools or bodies of water on the premises. Per licensee, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher was present (01) and serviced within the last 12 months. First aid kit(s) were complete and readily accessible.

LPA interviewed residents, and reviewed staff and resident records. During today’s visit there were 6 residents on the facility premise. LPA interviews did not raise any licensing concerns. The files which LPA reviewed contained required documents. Confidential records were stored in a locked area. Required licensing postings were observed in a visible area of the facility.

There was deficiencies observed and cited during today's annual inspection along with a technical violation and a technical advisory. The deficiencies observed during today’s inspection may be reviewed and is included on the LIC809-D page.

The report was discussed, a POC was jointly developed, and an exit interview was conducted with Licensee Bessie Pascual to whom a copy of this report along with the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit. The signature below confirms the documents were received.

LPA requested Licensee Pascual to submit a current Designation of Administrative Responsibility LIC 308, Personnel Report LIC 500, Emergency Disaster Plan LIC 610-E, and Residential Infection Control Plan LIC 9282 (6/23), to the licensing office within 10 business days. Forms are available at www.ccld.ca.gov.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Carmen Lopez	TELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/07/2023 06:37 PM - 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ST. ANTHONY'S BOARD AND CARE	FACILITY NUMBER: 374600449
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(27)

General Food Service Requirements

(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. 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 that there were cockaroaches in the kitchen, bathroom, and garage areas, which posed a potential personal rights risk to 6 of 6 persons in care.
	POC Due Date: 01/12/2024
	Plan of Correction
1 2 3 4	Licensee plans to call their pest control company for their services to be rendered weekly for the next month. Licensee will submit 4 receipts to LPA as confirmation that the pest control services were rendered to the facility and cockroaches were removed, due 1/12/2024.

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: Denise Powell	TELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Carmen Lopez	TELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

LIC809 (FAS) - (06/04)

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