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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201080
Report Date: 01/27/2024
Date Signed: 01/27/2024 12:01:17 PM

Document Has Been Signed on 01/27/2024 12:01 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: 6CENSUS: 5DATE:
01/27/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:BOOTSANSON FLORES CAREGIVERTIME COMPLETED:
01:00 PM
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On 1/27/2024 at 9:30am, Licensing Program Analyst (LPA) Carol Fowler returned to continue the 1-Year Required inspection that was started on 1/26/2024. LPA met with Caregiver, Bootsanson Flores. LPA informed the reason for visit. Chris Wilson Manager, arrived at approximately 10:15am.

LPA toured facility for corrections made, and completed reports.

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2024
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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