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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201080
Report Date: 05/26/2021
Date Signed: 05/26/2021 12:36:47 PM

Document Has Been Signed on 05/26/2021 12:36 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:ST. ANTHONY'S RESIDENTIAL CARE HOMEFACILITY NUMBER:
019201080
ADMINISTRATOR:WILSON, JOSEPHINE B.FACILITY TYPE:
740
ADDRESS:2661 LAKEVIEW DR.TELEPHONE:
(510) 908-1027
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY: 7CENSUS: 5DATE:
05/26/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Josephine Wilson, AdministratorTIME COMPLETED:
12:34 PM
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On 05/26/21 at 10:30AM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced pre-licensing inspection and met with administrator. LPA explained the reason for the visit. LPA observed 3 staff wearing masks. LPA also observed 5 residents resting in their bedrooms during visit.

LPA toured the facility inside and outside including but not limited to resident's bedrooms, bathrooms, dining room, common living areas, kitchen, and outside patios. There is sufficient lighting around the facility. Resident's rooms were equipped with the proper furniture and lighting. Resident's rooms had proper bedding and linens. Bathrooms were equipped with grab bars, nonskid mats, and hygiene items. Living room is equipped with the proper furniture for the residents. All toxins and sharp objects were locked. Passageways and hallways were free of obstruction. Fire extinguisher is fully charged. Smoke and Carbon Monoxide detectors were operational. Medication cabinet was locked and first aid kit was complete. Exit doors are equipped with auditory signals. Hot water temperature was measured at 109 degrees F. Sufficient 2 day perishable and 1 week non-perishable food supplies were observed in the refrigerator, freezer, kitchen pantry and additional food supplies were observed in the garage freezer. Emergency supplies were stored in the garage. Outdoor pool is fenced with a locking gate. Complaint poster, personal rights, Ombudsman and rights to council posters were observed displayed near the main entrance.

LPA observed no deficiencies during inspection. Facility is ready to be licensed. This report will be submitted to the central application unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAU. Additional requirements may still be required.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 05/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2021
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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