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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600449
Report Date: 07/12/2023
Date Signed: 07/12/2023 03:20:21 PM

Document Has Been Signed on 07/12/2023 03:20 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:ST. ANTHONY'S BOARD AND CAREFACILITY NUMBER:
374600449
ADMINISTRATOR:BESSIE PASCUALFACILITY TYPE:
740
ADDRESS:6533 PLAZA RIDGE ROADTELEPHONE:
(619) 470-4571
CITY:SAN DIEGOSTATE: CAZIP CODE:
92114
CAPACITY: 6CENSUS: 5DATE:
07/12/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator Bessie PascualTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator Bessie Pascual.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 05/30/2023). According to the LIC624, the facility had a cabinet where the personal monies of residents were kept. On the morning of 05/25/2023, Resident #1 (R1) went into this cabinet and took all the money for themselves. [See LIC811 Confidential Names List for a description of person identifiers used in this report.] Facility staff later recovered in full, all the money which R1 took.

During today’s visit, LPA, accompanied by the administrator, performed a facility tour, audited cash resource records, reviewed resident records, and interviewed pertinent staff. In addition to R1, the other residents in care were Resident #2 (R2), Resident #3 (R3), Resident #4 (R4), and Resident #5 (R5).

According to staff interview: During the incident, Staff #1 (S1) briefly stepped away from the cabinet where the resident monies were kept, to assist another resident in the bathroom. S1 left the cabinet unlocked, which allowed R1 to take the monies. Upon discovering that the monies had been taken, S1 alerted the administrator, who called staff at R1’s day program (where R1 had since traveled to). Staff at the day program secured R1’s permission to search their bag and located the monies in question (returning them to facility staff intact). A preponderance of evidence exists to show that during the above incident, licensee’s staff did not take appropriate measures to safeguard residents’ cash resources, as was required.

[CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: ST. ANTHONY'S BOARD AND CARE
FACILITY NUMBER: 374600449
VISIT DATE: 07/12/2023
NARRATIVE
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[CONTINUED FROM LIC 809]

The facility is currently licensed to care for up to six (6) residents in total, of which four (4) may be non-ambulatory, and none may be bedridden. Per R3’s latest LIC602 Physician’s Report (dated 06/28/2023), R3 had recently become bedridden. (Per their prior LIC602 dated 09/29/2022, they were formerly non-ambulatory). Based on the latest facility license and latest fire clearance, Licensee was not authorized to care for bedridden residents. Prior to today’s visit, Licensee did not notify CCLD or their local fire authority that R3 had become bedridden, nor did Licensee start the process of applying for bedridden capacity.

During records review, LPA observed: a) While Licensee maintained an active Surety Bond, the amount of the bond did not meet the minimum described in regulation, based on the actual amount of resident monies being safeguarded; b) Licensee did not possess a completed initial personal property inventory for R2, R3, and R4, as was required; and c) Licensee did not possess a completed Admissions Agreement for R3, as was required.

Deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC809-D pages). CCLD determined one of these violations resulted in the facility not complying with its approved Fire Clearance from the local fire authority. An immediate Civil Penalty of $500.00 is thus charged and is noted on the LIC421-IM. LPA also issued one (1) Technical Violation (TV) to Licensee regarding ledger accounting of cash resources.

An exit interview was conducted with Pascual, to whom a copy of this report, the LIC809-D pages, the LIC9102-TV, the LIC421-IM, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 07/12/2023 03:20 PM - It Cannot Be Edited


Created By: Dang Nguyen On 07/12/2023 at 02:09 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ST. ANTHONY'S BOARD AND CARE
FACILITY NUMBER: 374600449

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/13/2023
Section Cited
CCR
87202(a)(2)

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87202 Fire Clearance: “(a) All facilities shall maintain a fire clearance approved by the…district providing fire protection services, or the State Fire Marshall. Prior to accepting or retaining any of the following types of persons...the licensee shall notify the licensing agency and obtain an appropriate fire clearance…: (2) Bedridden persons.”
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By the POC due date, Licensee agreed to submit a cover letter and an LIC200 Application to the CCLD San Diego Regional Office (RO). The cover letter will state that R3 became bedridden on 06/28/2023, per their latest LIC602 Physician’s Report. The LIC200 will request permission for bedridden capacity of one (1) resident. These actions will prompt the RO to request a subsequent fire authority re-inspection for the facility.
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This requirement was not met, as evidenced by: Based on records review and interviews, Licensee did not notify the licensing agency and obtain an appropriate fire clearance prior to retaining a bedridden resident (R3), who was 1 of 5 residents, which posed an immediate safety risk to persons in care.
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Type B
08/11/2023
Section Cited
CCR87217(b)

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87217 Safeguards for Resident Cash, Personal Property, and Valuables: “(b) Every facility shall take appropriate measures to safeguard resident cash resources, personal property and valuables which have been entrusted to the licensee or facility staff.” This requirement was not met, as evidenced by:
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Per interviews, on 05/25/2023, Licensee retrained its direct care staff on the importance of keeping the cabinet where resident monies are held locked, whenever it is not in immediate use. Licensee agreed to send to LPA a training sign-in sheet reflecting this, by the POC due date.
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Based on records and interviews, the licensee did not take appropriate measures to safeguard resident cash resources that were entrusted to them, affecting 4 of 5 residents (R2 through R5), which posed a potential personal rights risk to persons in care.
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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.
SUPERVISOR'S NAME:Lizzette Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/12/2023 03:20 PM - It Cannot Be Edited


Created By: Dang Nguyen On 07/12/2023 at 02:14 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ST. ANTHONY'S BOARD AND CARE
FACILITY NUMBER: 374600449

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/11/2023
Section Cited
CCR
87216(a)(1)

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87216 Bonding: “(a) Each licensee…who is entrusted to safeguard resident cash resources, shall…have on file with the licensing agency a copy of a bond issued by a surety company to the State of California as principal. (1) The amount of the bond shall be in accordance with the following schedule: $750 or less safeguard = $1,000 bond required; $751 to $1,500 safeguarded = $2,000 bond required, $1,501 to $2,500 safeguarded = $3,000 bond required. Every further increment of $1,000 or fraction thereof shall require an additional $1,000 on the bond.”
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Licensee agreed to contact its surety bond company to increase its bond to $5,000. Licensee agreed to send to LPA a copy of a new/updated surety bond certificate, by the POC due date. During today’s visit, LPA printed out the text of 87216(a)(1), and its associated table, and handed it to licensee. Licensee agreed to keep this document inside their private office for future reference.
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This requirement was not met, as evidenced by: Based on record review and interview, licensee did not possess a surety bond meeting the minimum amount required per regulation, based on the actual amount of resident monies that Licensee was safeguarding, which affected 4 of 5 residents (R1 through R4), and posted a potential personal rights risk to persons in care.
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Type B
08/11/2023
Section Cited
CCR87218(a)(1)

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87218 Theft and Loss: “(a) The licensee shall ensure an adequate theft and loss program as specified in Health and Safety Code Section 1569.153. (1) The initial personal property inventory shall be completed by the licensee, and the resident, or the resident’s representative.”
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Licensee agreed to coordinate with persons, as needed, to complete updated LIC621 Personal Property inventory forms for all current residents (R1 through R5), and to send copies of these forms to LPA, by the POC due date. Licensee agreed to review their internal policies/procedures, to ensure that the LIC621 is treated as a required document at time of move-in.
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This requirement was not met, as evidenced by: Based on records and interviews, for 3 of 5 residents (R2, R3, and R4), Licensee did not maintain a personal property inventory, completed by the licensee and the resident and/or their representative, which posed a potential personal rights risk to persons in care.
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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.
SUPERVISOR'S NAME:Lizzette Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2023


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 07/12/2023 03:20 PM - It Cannot Be Edited


Created By: Dang Nguyen On 07/12/2023 at 02:18 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ST. ANTHONY'S BOARD AND CARE
FACILITY NUMBER: 374600449

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/11/2023
Section Cited
CCR
87505(a)

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87505 Admissions Agreements: “(a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any.” This requirement was not met, as evidenced by:
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Licensee agreed to coordinate with persons, as needed, to complete an Admissions Agreement for R3. Licensee agreed to send a copy of the Admissions Agreement to LPA, by the POC due date. Licensee agreed to review their internal policies/procedures, to ensure that the signed Admissions Agreement is treated as a required document at time of move-in.
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Based on LPA observation and staff interview, for 1 of 5 residents (R3), licensee did not complete an individual written admission agreement, which posed a potential personal rights risk to persons in care.
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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.
SUPERVISOR'S NAME:Lizzette Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2023


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