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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374601166
Report Date: 05/25/2023
Date Signed: 05/25/2023 12:09:06 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/19/2023 and conducted by Evaluator Dawn Segura
COMPLAINT CONTROL NUMBER: 08-AS-20230519133242
FACILITY NAME:ANTHONY GUEST HOMEFACILITY NUMBER:
374601166
ADMINISTRATOR:ANTONIO C. BALANZAFACILITY TYPE:
735
ADDRESS:14435 HIGH PINE STREETTELEPHONE:
(858) 748-3669
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY:6CENSUS: 5DATE:
05/25/2023
UNANNOUNCEDTIME BEGAN:
10:53 AM
MET WITH:Solema Canto, StaffTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Hazardous items were left accessible to clients in care.

Licensee did not maintain current client medication records.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Dawn Segura conducted an unannounced visit to conduct an investigation into the above listed complaint allegations. LPA introduced herself, was granted entry, and met with Solema Canto, Staff, to whom she disclosed the purpose of the visit.

Community Care Licensing (CCL) has investigated the above listed allegations. The investigation consisted of a tour of the facility, review of facility records, observation of client medications, and interview of facility staff.

It was reported that a toxic cleaning chemical was left in an unlocked cabinet under the sink in the bathroom utilized by clients and that yard tools were left unlocked and exposed in the back yard of the facility, which is an area that is accessible to clients. Staff interview, photographic evidence obtained by CCL, and LPA observation confirmed that several outdoor yard tools, including a shovel, pitchfork, gardening hoe, and weeder with spikes, were found outdoors in an unsecured area. LPA also observed that Ajax with bleach
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dawn Segura
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 08-AS-20230519133242
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: ANTHONY GUEST HOME
FACILITY NUMBER: 374601166
VISIT DATE: 05/25/2023
NARRATIVE
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powder was in an unsecured cabinet in a bathroom utilized by clients.

It was also alleged that the licensee was maintaining a medication administration record (MAR) that was inaccurate. It was reported that medications for Client 1 (C1) [LIC 811 Confidential Names List was provided to identity the client] were still in the bubble packs; however, the MAR reflected that the medications had been administered. The investigation yielded that a night time medication for C1 and 3 medications to be administered to C1 on 5/18/2023 were still in the bubble packs in the early part of the day on 5/17/2023; however, the MAR was initialed as if the 4 medications had already been administered.

Based upon interview conducted, records reviewed, evidence collected, and LPA observation, the above listed allegations are substantiated. This finding means that the preponderance of the evidence standard has been met and the allegations are valid. Deficiencies are cited in accordance with California Code of Regulations, Title 22, Division 6, Chapter 8 and noted on the attached LIC 9099-D.

An exit interview was conducted, and a copies of this report and Licensee Appeal Rights (LIC 9058) were provided to Solema Canto at the conclusion of the visit. Her signature on this report acknowledges receipt of copies of the rights and the report.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dawn Segura
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20230519133242
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ANTHONY GUEST HOME
FACILITY NUMBER: 374601166
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/22/2023
Section Cited
CCR
80087(g)
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Buildings and Grounds. Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.
This requirement was not met, as evidenced by:
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Staff stored the toxin and yard tools in secured areas during the visit. Staff agreed to ensure that all staff receive training relative to proper storage and handling of toxins. Proof of training will be provided to CCL by the POC due, which is 6/22/2023.
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Based on interview and observation, licensee did not ensure that a disinfectant cleaning product and outdoor garden tools were stored where they were inaccessible to 5 of 5 clients in care. This posed a potential health and safety risk to persons in care.
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Type B
06/22/2023
Section Cited
CCR
80070(a)
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Client Records. The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.

This requirement was not met, as evidenced by:
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Staff offered to ensure that all staff receive medication training from an outside vendor and provide proof of training to CCL by the POC due date which is 6/22/2023.
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Based on record review and interview, licensee did not maintain a current medication administration record for C1, 1 of 5 clients in care. This posed a potential health risk for persons in care.
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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.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dawn Segura
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3