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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201080
Report Date: 03/28/2025
Date Signed: 04/08/2025 08:46:11 AM

Document Has Been Signed on 04/08/2025 08:46 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:ST. ANTHONY'S RESIDENTIAL CARE HOMEFACILITY NUMBER:
019201080
ADMINISTRATOR/
DIRECTOR:		WILSON, JOSEPHINE B.FACILITY TYPE:
740
ADDRESS:2661 LAKEVIEW DR.TELEPHONE:
(510) 908-1027
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY: 6CENSUS: 6DATE:
03/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Licensee Josephine B. WilsonTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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On 03/28/2025 at 11:00 am Licensing Program Analysts (LPAs) Yasamin Brown and James Sampair arrived unannounced to do an annual inspection. LPAs meet with Administrator Josephine Wilson and explained the purpose of the visit.

LPAs inspected the facility inside out. LPAs 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. LPAs observed the room temperature 78 degrees Fahrenheit he water temperature at 106.2 degrees.

Continued on LIC809-C..
NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Yasamin Brown
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2025
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 6
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 04/08/2025 08:46 AM - It Cannot Be Edited


Created By: Yasamin Brown On 03/28/2025 at 01:40 PM
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: 03/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)(1)
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: (1) Nonambulatory persons.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in that facility has all non-ambulatory residents when the license is fire cleared for all ambulatory which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2025
Plan of Correction
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On or before the due date, the Licensee shall complete and submit an LIC 200 for a change in ambulatory status. Additionally, an informal conference with CCLD will be scheduled at a later time.
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that LPAs observed unlocked cabinets with sharp knives inside. LPAs also observed unlocked outdoor cabinet with a gallon of deadweed brew, Resolve stain carpet cleaner, and two gallons of open paint which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2025
Plan of Correction
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DEFICIENCY CLEARED DURING VISIT.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Yasamin Brown
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2025


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 04/08/2025 08:46 AM - It Cannot Be Edited


Created By: Yasamin Brown On 03/28/2025 at 01:40 PM
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: 03/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87113
Posting of License
The license shall be posted in a prominent location in the licensed facility accessible to public view.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. The current license with a Hayward address was incorrectly posted, which poses a potential health and safety risk to persons in care.
POC Due Date: 03/28/2025
Plan of Correction
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DEFICIENCY CLEARED DURING VISIT.
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that LPAs observed that 0/6 staff members did not have there CPR/First Aid Certificates updated which poses a health, and safety risk to persons in care.
POC Due Date: 04/04/2025
Plan of Correction
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Administrator shall provide proof that first aid training has been scheduled on or before the end of April 2025 for all staff.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Yasamin Brown
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2025


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 04/08/2025 08:46 AM - It Cannot Be Edited


Created By: Yasamin Brown On 03/28/2025 at 01:40 PM
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: 03/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(c)(5)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (5) The determination whether the person is ambulatory or nonambulatory as defined in Section 87101, Definitions, or bedridden as defined in Health and Safety Code section 1569.72. The assessment shall indicate whether nonambulatory status is based upon the resident's physical condition, mental condition, or both.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. 0 of 6 residents had medical assessments completed within 12 months, which poses a potential health and safety risk to persons in care.
POC Due Date: 04/04/2025
Plan of Correction
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On or before the due date the Licensee shall schedule or provide proof of an updated medical assessment for all six of the residents.
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.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Yasamin Brown
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2025


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ST. ANTHONY'S RESIDENTIAL CARE HOME
FACILITY NUMBER: 019201080
VISIT DATE: 03/28/2025
NARRATIVE
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...Continued from LIC808.

LPAs observed the following deficiencies:
  • At 11:30AM,LPAs observed facility having all non-ambulatory residents.
  • At 11:37AM, LPAs observed that Licensee did not have the current license posted.
  • At 12:05PM, LPAs observed unlocked cabinets with sharp knives inside. LPAs also observed unlocked outdoor cabinet with a gallon of Deadweed brew, Resolve stain carpet cleaner, and two gallons of open paint.
  • At 12:15PM, LPAs observed that 0/6 staff members did not have there CPR/First Aid Certificates updated.
  • At 12:30, LPAs observed during record review that residents did not have records for medical assessment.

Two (2) A type citations and three (3) B type citations issued during visit.
Two (2) Civil Penalties issued during visit.

Civil Penalties totaling $750 have been assessed today for failure to meet POC due dates for the deficiencies above. Facility is subject to ongoing daily civil penalties until proof of corrected deficiencies have been sent to Community Care Licensing (CCL).


Deficiencies are cited from Title 22 California Code of Regulations (see 809D's). Failure to submit proof of correction may result in additional civil penalty.

Exit interview conducted and a copy of this report provided.
NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Yasamin Brown
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025
LIC809 (FAS) - (06/04)
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