374600449-8-30-2023-08-AS-DNGN-CV82R2-20230830173649

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374600449
Report Date: 08/30/2023
Date Signed: 08/30/2023 05:37:19 PM

Document Has Been Signed on 08/30/2023 05:37 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	ST. ANTHONY'S BOARD AND CARE		FACILITY NUMBER:	374600449
ADMINISTRATOR:	BESSIE PASCUAL		FACILITY TYPE:	740
ADDRESS:	6533 PLAZA RIDGE ROAD		TELEPHONE:	(619) 470-4571
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92114
CAPACITY: 6		CENSUS: 5	DATE:	08/30/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	02:50 PM
MET WITH:	Caregiver Nanita Abat and Administrator Bessie Pascual		TIME COMPLETED:	05:45 PM

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Licensing Program Analysts (LPA) Dang Nguyen and Amy Rodgers conducted an unannounced Case Management - Incident visit. LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit with Caregiver Nanita Abat. LPAs also spoke with Administrator Bessie Pascual, who joined a portion of the visit via phone.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 08/28/2023). According to the LIC624: during the morning of 08/25/2023, Resident #1 (R1) eloped from the facility (left without staff supervision). [See LIC 811 Confidential Names List for a description of R1.] Police located R1 unharmed and returned them to the facility, later the same morning.

During today’s visit, LPAs performed a facility tour and welfare check. On the date of LPAs’ visit, R1 was off-site at a skilled nursing facility (for separate health reasons, not a result of the elopement). R1’s housemates were safe. LPAs also reviewed pertinent facility care records and interviewed relevant staff.

According to their latest LIC602 Physician’s Report (dated 06/08/2023), R1 was diagnosed with schizophrenia and intellectual disability (among other diagnoses), and their doctor determined that they were not able to safely leave the facility unassisted.

Staff interviews, corroborated by care records, showed: R1 was able to toilet, bathe, and dress themselves independently. R1 had not eloped or attempted to elope from the facility prior to the incident in question. On 08/25/2023, Staff #1 (S1) observed R1 use the shower at 1:00 AM, and then use the bathroom at 3:00 AM and 4:00 AM, respectively. Around 5:15 AM, S1 observed the facility’s kitchen door was left open, and first recognized that R1 was not present inside the facility. S1 notified the administrator, who joined the search for R1. [CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023

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: 08/30/2023

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[CONTINUED FROM LIC 809] Not having located R1, the administrator phoned San Diego Police Department (SDPD) around 8:30 AM to report R1 as a missing person. Around 9:45 AM, a bystander encountered R1 at bus stop in another city and recognized that R1 needed help. With this tip, SDPD picked up R1 and returned them to the facility unharmed around 11:56 AM.

Record review, corroborated by manager interview, showed: Licensee did not develop and maintain a written Absentee Notification Plan as part of the written record of care for 5 of 5 current residents in care (R1 through R5). One (1) deficiency was thus cited per California Health and Safety Code (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the licensee. LPAs also issued Technical Assistance (TA) regarding installing staff auditory alert devices on the facility's perimeter/exteriour doors.

An exit interview was conducted with Pascual via phone. A copy of this report, the LIC809-D, the LIC9102-TA, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided to her via E-mail, during the visit.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/30/2023 05:37 PM - It Cannot Be Edited

Created By: Dang Nguyen On 08/30/2023 at 05:12 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: 08/30/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/29/2023 Section Cited HSC 1569.317	1 2 3 4 5 6 7	1569.317 Absentee Notification Plan for Missing Residents: “Every residential care facility for the elderly…shall…develop and comply with an absentee notification plan…The plan shall include…a requirement that an administrator of the facility, or his or her designee, inform the resident’s authorized representative when that resident is missing from the facility…and the circumstances in which [they] shall notify local law enforcement.”	1 2 3 4 5 6 7	Licensee agreed to author an Absentee Notification Plan meeting the requirements of California Health and Safety Code 1569.317. Licensee agreed to add it to the written record of care for R1 through R5 (and all future move-ins, too), and to train its direct care staff on it. Licensee agreed to send a copy of its Absentee Notification Plan, and the team training sign-in sheet, to LPA Nguyen, by the POC due date.
	8 9 10 11 12 13 14	This requirement was not met, as evidenced by: Based on records and interview, the Licensee did not develop an absentee notification plan for 5 of 5 residents (R1 through R5), which posed a potential safety risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 08/30/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023

LIC809 (FAS) - (06/04)

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