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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
019201080
Report Date:
05/24/2024
Date Signed:
05/24/2024 12:48:24 PM
Document Has Been Signed on
05/24/2024 12:48 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 HOME
FACILITY NUMBER:
019201080
ADMINISTRATOR/
DIRECTOR:
WILSON, JOSEPHINE B.
FACILITY TYPE:
740
ADDRESS:
2661 LAKEVIEW DR.
TELEPHONE:
(510) 908-1027
CITY:
SAN LEANDRO
STATE:
CA
ZIP CODE:
94577
CAPACITY:
6
CENSUS:
6
DATE:
05/24/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:
Josephine Wilson, Licensee
TIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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On 05/24/24 at 9:00 am Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to do an annual inspection. LPA meet with Administrator Josephine Wilson and explained the purpose of the visit.
LPA inspected the facility inside out. Physical plant is consistent with the facility sketch received by Central Application Bureau (CAB) and approved by the fire department. LPA inspected the living room, dining area, kitchen, bedrooms, hallways, bathrooms, side and backyards. Bedrooms were observed appropriately furnished with adequate lighting and drawers. Facility has sufficient towels, extra bed sheets and comforters. Equipment and supplies for residents' personal hygiene are available and on site. Dinner and silver wares were observed sufficient for residents' use. Food supplies checked and observed good for seven days of non-perishables. Facility was observed equipped with refrigerator, microwave, dishwasher, washer and dryer. Activity supplies were available. Outdoor activity space was observed furnished with tables, chairs and shade. The facility has a mitigation plan. Fire extinguishers were observed fully charge and tags showed serviced 01/26/2024.
At 10:02 am LPA reviewed 6 residents records. At 10:45 am, LPA reviewed 2 staff records and 2 of 2 were fingerprint cleared and associated to the facility.
The following deficiency was observed during the visit:
LPA observed medication left out on table
LPA observed chemical cleaners left out in bathroom and around the house
repeat violation
LPA observed bugs flying around the in kitchen
LPA observed a mouse in garage
repeat violation
Continued on LIC809-C...
SUPERVISORS NAME
:
Harpreet Humpal
LICENSING EVALUATOR NAME
:
Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE
:
DATE:
05/24/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/24/2024
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
7
Document Has Been Signed on
05/24/2024 12:48 PM
- It Cannot Be Edited
Created By:
Jill Clancy-Czuleger
On
05/24/2024
at
11:18 AM
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
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
ST. ANTHONY'S RESIDENTIAL CARE HOME
FACILITY NUMBER:
019201080
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
05/24/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by having a bike lock keeping the emergency exit gate locked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
05/31/2024
Plan of Correction
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2
3
4
The facility agrees to remove the lock. Proof of correction will be sent to CCLD by POC date.
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by having chemicals left out in the residents bathroom which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
05/31/2024
Plan of Correction
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2
3
4
The facility will remove the cleaning chemicals and secure them in a locked location. Proof of correction will be sent to CCLD by POC date. Civil penalty of $1000 is assessed for repeat violation.
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:
Harpreet Humpal
LICENSING EVALUATOR NAME:
Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:
DATE:
05/24/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/24/2024
LIC809
(FAS) - (06/04)
Page:
2
of
7
Document Has Been Signed on
05/24/2024 12:48 PM
- It Cannot Be Edited
Created By:
Jill Clancy-Czuleger
On
05/24/2024
at
11:18 AM
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
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
ST. ANTHONY'S RESIDENTIAL CARE HOME
FACILITY NUMBER:
019201080
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
05/24/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)(1)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above by having knifes left in an unlocked drawer in the kitchen which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
05/27/2024
Plan of Correction
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2
3
4
The facility will remove the knifes and secure them in a locked location. Proof of correction will be sent to CCLD by POC date. Civil penalty of $1000 is assessed for repeat violation.
Type A
Section Cited
CCR
87309(b)
Storage Space
(b) Medicines shall be stored as specified in Section 87465(c) and separately from other items specified in (a) above.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by having medications left out which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
05/28/2024
Plan of Correction
1
2
3
4
The facility will remove the medications and secure them in a locked location. Proof of correction will be sent to CCLD by POC date.
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:
Harpreet Humpal
LICENSING EVALUATOR NAME:
Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:
DATE:
05/24/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/24/2024
LIC809
(FAS) - (06/04)
Page:
3
of
7
Document Has Been Signed on
05/24/2024 12:48 PM
- It Cannot Be Edited
Created By:
Jill Clancy-Czuleger
On
05/24/2024
at
11:18 AM
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
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
ST. ANTHONY'S RESIDENTIAL CARE HOME
FACILITY NUMBER:
019201080
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
05/24/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by having the medication cabinet unlocked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
05/24/2024
Plan of Correction
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2
3
4
POC cleared during visit.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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:
Harpreet Humpal
LICENSING EVALUATOR NAME:
Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:
DATE:
05/24/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/24/2024
LIC809
(FAS) - (06/04)
Page:
4
of
7
Document Has Been Signed on
05/24/2024 12:48 PM
- It Cannot Be Edited
Created By:
Jill Clancy-Czuleger
On
05/24/2024
at
11:18 AM
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
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
ST. ANTHONY'S RESIDENTIAL CARE HOME
FACILITY NUMBER:
019201080
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
05/24/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by allowing staff to live in the shed that does not have fire clearances which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
05/31/2024
Plan of Correction
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3
4
The facility agrees to remove staff from shed and request a new fire clearance before anyone lives in there. Proof of correction will be sent to CCLD by POC date.
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above because there was a mouse in the garage of the facility which poses/posed a potential health, safety or personal rights risk to persons in care. mouse
POC Due Date:
06/07/2024
Plan of Correction
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2
3
4
Licensee agrees to have a pest control company treat facility for pests. Proof of correction will be sent to CCLD by POC date. Civil penalty of $1000 is assessed for repeat violation.
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:
Harpreet Humpal
LICENSING EVALUATOR NAME:
Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:
DATE:
05/24/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/24/2024
LIC809
(FAS) - (06/04)
Page:
5
of
7
Document Has Been Signed on
05/24/2024 12:48 PM
- It Cannot Be Edited
Created By:
Jill Clancy-Czuleger
On
05/24/2024
at
11:18 AM
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
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
ST. ANTHONY'S RESIDENTIAL CARE HOME
FACILITY NUMBER:
019201080
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
05/24/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(27)
General Food Service Requirements
(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by having fruit flies in the kitchen which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
06/07/2024
Plan of Correction
1
2
3
4
Licensee agrees to have a pest control company treat facility for pests. Proof of correction will be sent to CCLD by POC date
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:
Harpreet Humpal
LICENSING EVALUATOR NAME:
Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:
DATE:
05/24/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/24/2024
LIC809
(FAS) - (06/04)
Page:
6
of
7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
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 HOME
FACILITY NUMBER:
019201080
VISIT DATE:
05/24/2024
NARRATIVE
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... Continued from LIC 809
LPA observed staff living in shed
LPA observed bike lock on exit gate
LPA observed knifes in unlocked drawer
repeat violation
LPA observed medication cabinet unlocked
A civil penalty is being assessed today for $3000 for all repeat violations {$1000 per violation x 3}
The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.
Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME
:
Harpreet Humpal
LICENSING EVALUATOR NAME
:
Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE
:
DATE:
05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/24/2024
LIC809
(FAS) - (06/04)
Page:
7
of
7