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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294209
Report Date: 08/27/2024
Date Signed: 08/27/2024 04:56:52 PM


Document Has Been Signed on 08/27/2024 04:56 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:SAINT ANTHONY'S CARE HOME FOR THE ELDERLYFACILITY NUMBER:
435294209
ADMINISTRATOR:CASTILLEJO, EUGENE J.FACILITY TYPE:
740
ADDRESS:3258 EVCO COURTTELEPHONE:
(408) 708-4758
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY:6CENSUS: 4DATE:
08/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Eugene CastillejoTIME COMPLETED:
11:59 AM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) Eugene Castillejo.

LPA reviewed 2 resident files and 2 staff files.

LPA toured the facility inside out with ADM. License, Administrator Certificate, and personal rights posters were observed at the main entrance. Living room, kitchen, dinning room, garage, and two restrooms were inspected. Bars and non skid mats were observed. Three resident bedrooms, and laundry room were inspected. One staff live-in room was observed in facility. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication closet, knives closet, and cleaning product closet were observed locked. Room temperature was at 74 degree F, and hot water temperature was at 109 degree F in facility. 4 residents and 2 staff were observed in facility.

The fire extinguisher was serviced on 8/3/24. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways.

First aid box, flash light, and night lights were observed in the facility. The last time the facility conducted emergency drill is on 7/18/2024.

Deficiencies were noted today. See LIC809-D. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of the report was provided to ADM.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2024
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 3


Document Has Been Signed on 08/27/2024 04:56 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131


FACILITY NAME: SAINT ANTHONY'S CARE HOME FOR THE ELDERLY
FACILITY NUMBER: 435294209

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that one resident's physician report was conducted at the year when the resident was admitted in the facility which is more than 2 years which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/03/2024
Plan of Correction
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Administrator stated to send a plan of correction by the POC due date to have the resident to have a doctor appointment to conduct a medical assessment and to maintain resident yearly physician report.
Type B
Section Cited
CCR
87463(c)
Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that one resident's appraisal needs and service plan was conducted 3 years ago which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/03/2024
Plan of Correction
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Administrator stated to send a plan of correction by the POC due date to maintain residents' yearly appraisal needs and service plan.
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: Romeo ManzanoTELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 08/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 08/27/2024 04:56 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131


FACILITY NAME: SAINT ANTHONY'S CARE HOME FOR THE ELDERLY
FACILITY NUMBER: 435294209

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87508(a)(3)
Register of Residents
(a) The licensee shall ensure that a current register of all residents in the facility is maintained and contains the following updated information: (3) Information on the resident's responsible person as specified in Section 87506(b)(6).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that one resident files did not have the emergency contact information and phone number which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/03/2024
Plan of Correction
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Administrator stated to send a plan of correction by the POC due date to maintain resident's' emergency contact and phone number up to date.
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: Romeo ManzanoTELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 08/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2024
LIC809 (FAS) - (06/04)
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