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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600997
Report Date: 11/04/2022
Date Signed: 11/04/2022 01:07:35 PM

Document Has Been Signed on 11/04/2022 01:07 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:ST. ANTHONY'S HOMEFACILITY NUMBER:
415600997
ADMINISTRATOR:RIZZI BUIFACILITY TYPE:
734
ADDRESS:3250 CRESTMOOR DRIVETELEPHONE:
(650) 742-1058
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 4CENSUS: 3DATE:
11/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Kaila Branch and Luz CanaresTIME COMPLETED:
01:15 PM
NARRATIVE
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LPA Audrey Jeung toured facility and grounds. No accessible bodies of water or fire safety hazards are observed. There are 4 private bedrooms for residents and 2 common bathrooms. There is a 2 car garage used for storage. There is a wood deck in the backyard.
Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. PPE supply is adequate and infection control signs are posted prominently. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Soap and paper towels are present in bathrooms and kitchen sink, including reminder signs to wash hands. Toilet and bathing facilities are equipped with grab bars and nonskid flooring material. First-aid kit is inspected and complete. An updated Disaster and Mass Casualty Plan is posted. There are 3 residents present, and 2 staff. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, and staff have current first-aid training. Rizzi Bui Calamucha is the administrator that oversees facility operations.

The following form is provided to LPA today:
• LIC 610D Emergency Disaster Plan

The following forms/information are requested to be submitted to CCLD by 11/18/22:
• LIC 309 Administrative Organization
• LIC 308 Designation of Administrative Responsibility
• LIC 500 Personnel Report
• LIC 400 Affidavit Regarding Client Cash Resources
• LIC 610D Emergency Disaster Plan (revised 9 page version)

Deficiency of the General Licensing Regulations, of the California Code of Regulations, Title 22, Division 6, Chapter 1, Articles 1-7 is observed and cited on a following page.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2022
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 11/04/2022 01:07 PM - It Cannot Be Edited


Created By: Audrey Jeung On 11/04/2022 at 12:42 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: ST. ANTHONY'S HOME
FACILITY NUMBER: 415600997

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(2)
All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility request a transfer of a criminal record clearance as specified in Section 80019(f)

This requirement is not met as 2 staff who are on schedule at this faciity do not have criminal record clearances assoicated to this facility.
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as 2 out of 14 staff do not have criminal record clearances associated to this facility. This poses an immediate health, safety or personal rights risk to persons in care. However, their criminal record clearances are associated to licensee's other facilities.
POC Due Date: 11/07/2022
Plan of Correction
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Requests to transfer criminal record clearances for staff LL and EC to be submitted to CCLD with photo ID by due date. Alternatively, transfer of criminal record clearances can be done through Guardian portal by authorized facility representative.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Cara Smith
LICENSING EVALUATOR NAME:Audrey Jeung
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2022


LIC809 (FAS) - (06/04)
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