374601166-5-27-2026-08-AS-CLOZ-DUH3LA-20260527182026

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374601166
Report Date: 05/27/2026
Date Signed: 05/27/2026 06:21:41 PM

Document Has Been Signed on 05/27/2026 06:21 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:	ANTHONY GUEST HOME		FACILITY NUMBER:	374601166
ADMINISTRATOR/ DIRECTOR:	ANTONIO C. BALANZA		FACILITY TYPE:	735
ADDRESS:	14435 HIGH PINE STREET		TELEPHONE:	(858) 748-3669
CITY:	POWAY	STATE: CA	ZIP CODE:	92064
CAPACITY: 6		CENSUS: 5	DATE:	05/27/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Caregivers, Maribeth Adonay and Cleotilde Menes		TIME VISIT/ INSPECTION COMPLETED:	06:30 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 identified herself and was granted entry by caregivers, Maribeth Adonay and Cleotilde Menes. LPA discussed the purpose of the visit with caregivers Adonay and Menes, and Licensee Antonio Balanza who arrived later at the exit of the visit. According to the facility’s license, there may be a maximum of 6 clients, all of whom may be ambulatory at any given time at the facility site. During today’s inspection, the facility’s current census is five (5) clients living at the facility. There was one (1) client present at the facility site during the inspection. LPA inspected the interior and exterior of the facility and inspected each room. The facility was clean, sanitary and in good repair. There was one client who opted not to have caregivers enter their room and said they would prefer to take out their items to be laundered. Pathways were free of obstruction and slip hazards. Client 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 70ºF. Hot water temperature at taps accessible to clients became compliant during the inspection. There were no labels or warning signs posted. There were at least 2 days of perishable food, and at least 7 days of non-perishable food present. Cooking, dining equipment and utensils were present, and all safely stored. There were no toxic chemicals or poisons accessible to clients. [CONTINUED ON LIC 809-C]

NAME OF LICENSING PROGRAM MANAGER: Robyn Clark
NAME OF LICENSING PROGRAM ANALYST: Carmen Lopez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/27/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: ANTHONY GUEST HOME	FACILITY NUMBER: 374601166
	VISIT DATE: 05/27/2026

NARRATIVE

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[CONTINUED FROM LIC 809]

Most medications were labeled as required with the exception of one medication which a minor discrepancy by the pharmacy was observed but the licensee corrected with the pharmacy during the inspection. Medications were stored in locked cabinet, which LPA inspected. The facility-maintained medication logs, which LPA reviewed. LPA inquired about glucose monitoring and the caregivers said that the nurses come and assist clients on occasions but were not monitoring the glucose of clients at the facility. According to Licensee they will be communicating with the clients PCP and move forward with their direction.

No pools or bodies of water on the premises. Per caregiver Maribeth Adonay, no firearms or ammunition are kept at the facility. Facility had a fireplace that was inaccessible to clients. Carbon monoxide detectors, emergency lighting, and the facility telephone were all working. Fire extinguishers were present (01) and serviced within the last 12 months. The first aid kit was readily accessible and a new kit will be delivered on 05/29/2026, but needed an operating thermometer. Licensee ordered the thermometer during the inspection and will be delivered on 05/27/2026.

Administrative records were reviewed. Licensee’s Administrative certificate is up to date and will expire June 2027. The facility sketch that LPA reviewed did not depict the current layout. According to the facility sketch, the staff room downstairs, based on observations the staff room is currently being used as a client bedroom. Licensee sent an updated facility sketch to the Department during the inspection.

LPA spoke with staff and clients, and reviewed staff and client records. LPA spoke with the Licensee regarding licensing concerns. The files that LPA reviewed contained the most required documents. Confidential records were stored in a locked area of the facility. Required licensing postings were observed in a visible area of the facility.

There were deficiencies observed and cited during today's annual inspection, and the facility received Technical Violations (TV)/Technical Advisories (TAs) which may be found on the LIC809-D and TA/TV 9102s pages within this report.

An exit interview was conducted with Licensee Antonio Balanza, 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 that the documents were received.

LPA received a current Designation of Administrative Responsibility (LIC 308) and Personnel Report (LIC 500), during the visit. LPA requested Licensee Antonio Balanza to submit a current Emergency Disaster Plan (LIC610-D) to the licensing office within 10 business days. Forms are available at www.ccld.ca.gov.

NAME OF LICENSING PROGRAM MANAGER: Robyn Clark
NAME OF LICENSING PROGRAM ANALYST: Carmen Lopez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/27/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/27/2026 06:21 PM - It Cannot Be Edited

Created By: Carmen Lopez On 05/27/2026 at 04:13 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ANTHONY GUEST HOME	FACILITY NUMBER: 374601166
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 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 2 out of 2 client bathrooms maintained hot water temperatures higher than the allotted ranges which posed an immediate safety risk to persons in care.
	POC Due Date: 05/27/2026
	Plan of Correction
1 2 3 4	The hot water temperatures were decreased during LPAs visit. This is deemed cleared during the visit.

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.

	Robyn Clark
NAME OF LICENSING PROGRAM MANAGER:

	Carmen Lopez
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/27/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2026

LIC809 (FAS) - (06/04)

Page: 4 of 13

Document Has Been Signed on 05/27/2026 06:21 PM - It Cannot Be Edited

Created By: Carmen Lopez On 05/27/2026 at 04:13 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ANTHONY GUEST HOME	FACILITY NUMBER: 374601166
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85095.5(b)(2)(C)

Infection Control Requirements

(b) In addition to subsection (a), when one or more clients in the facility are diagnosed with a contagious disease, the following shall apply: (2) All staff and volunteers providing direct care to a client who has a contagious disease shall wear appropriate Personal Protective Equipment (PPE) to prevent exposure to infectious agents or chemicals through the respiratory system, skin, or mucous membranes of the eyes, nose, or mouth. PPE may include gloves, gowns, masks, respirators, shoe coverings and eye protection. (C) The licensee shall ensure all staff and volunteers are trained in the proper use of all required PPE prior to being around clients and annually thereafter. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in 2 out od 2 staff did not have their infection control training was completed annually which posed a potential health, safety and personal rights risk to persons in care.
	POC Due Date: 06/11/2026
	Plan of Correction
1 2 3 4	Facility agreed to have staff trained on infection control protocols and submit training documents to LPA by POC due date, 06/11/2026.

Type B

Section Cited

CCR

80069(b)(1)

Client Medical Assessments

(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment. (1) Such assessment shall be performed by a licensed physician, or designee, who is also a licensed professional, and the assessment shall not be more than one year old when obtained. 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 in 5 out of 5 clients did not have an updated medical assessment which posed a potential health risk to persons in care.
	POC Due Date: 06/11/2026
	Plan of Correction
1 2 3 4	The licensee agreed to schedule appointments for the clients and send LPA the dates of the scheduled appoinements by POC due date 06/11/2026. Licensee agreed to place updated medical assessments in clients files once updated and obtained by their PCPs.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Robyn Clark
NAME OF LICENSING PROGRAM MANAGER:

	Carmen Lopez
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/27/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/27/2026 06:21 PM - It Cannot Be Edited

Created By: Carmen Lopez On 05/27/2026 at 04:13 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ANTHONY GUEST HOME	FACILITY NUMBER: 374601166
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80069(c)(1)

Client Medical Assessments

(c) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases. 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 in 1 (C1) out of 5 clients did not have their TB on file which posed a potential health and personal rights risk to persons in care.
	POC Due Date: 06/11/2026
	Plan of Correction
1 2 3 4	The Licensee agreed to schedule an appointment for C1 to obtain a TB test and submit the scheduled appointment time to LPA by POC due date 06/11/2026, or their results.

Type B

Section Cited

CCR

85070(a)(3)

Client Records

(a) In addition to Section 80070, each client record must contain the following information: (3) Needs and Services Plan and any modifications thereto, as specified in Sections 80068.2, 80068.3, 85068.2 and 85068.3. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Prior to LPAs departure, Licensee arrived with the updated individual service plan's for all clients.
	POC Due Date: 05/27/2026
	Plan of Correction
1 2 3 4	This is deemed cleared during today's 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.

	Robyn Clark
NAME OF LICENSING PROGRAM MANAGER:

	Carmen Lopez
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/27/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2026

LIC809 (FAS) - (06/04)

Page: 6 of 13

Document Has Been Signed on 05/27/2026 06:21 PM - It Cannot Be Edited

Created By: Carmen Lopez On 05/27/2026 at 04:13 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ANTHONY GUEST HOME	FACILITY NUMBER: 374601166
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80092.1(f)(2)

General Requirements for Restricted Health Conditions

(f) Prior to admission of a client with a restricted health condition specified in Section 80092, the licensee shall: (2) Ensure that facility staff who will participate in meeting the client's specialized care needs complete training provided by a licensed professional sufficient to meet those needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above in 3 out of 3 clients did not have a staff to assist with meeting their glucose care needs which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/11/2026
	Plan of Correction
1 2 3 4	Based on the section cited below, this is considered to be obsolete until the licensee speaks with the clients PCPs. This is deemed cleared during today's visit.

Type B

Section Cited

CCR

80092.8(a)(2)

The client is mentally and physically capable in administering his/her own medication and perform his/her own glucose testing, if applicable, or a licensed professional administers the test and injections. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in 3 out of 5 clients did not have their glucose tested which poses a potential health risk to persons in care.
	POC Due Date: 06/29/2026
	Plan of Correction
1 2 3 4	The licensee agreed to speak with the C1 and C2, PCPs to ensure that glucose is monitored by the facility for clients. Licensee agreed to submit a plan, to LPA via email, on how that facility will be monitoring C1 and C2s glucose levels by POC due date, 06/29/2026. According to C3s nurse, they do not have diabetes whic cleared C3 from this POC.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Robyn Clark
NAME OF LICENSING PROGRAM MANAGER:

	Carmen Lopez
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/27/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2026

LIC809 (FAS) - (06/04)

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