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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 12:37:31 PM

Document Has Been Signed on 05/26/2021 12:37 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:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Josephine Wilson, AdministratorTIME COMPLETED:
12:30 PM
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On 05/26/21 at 12PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted a Component III presentation during the pre-licensing visit and met with administrator.

LPA explained the most common deficiencies cited in Residential Care facilities with administrator and discussed how to avoid them. Administrator agreed to be in compliance with Title 22 regulations and share Provider Information Notice (PINs) updates with staff, residents, visitors and their representatives.

Exit interview conducted and a copy of this report provided to administrator.
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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