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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600449
Report Date: 12/04/2024
Date Signed: 12/04/2024 03:38:48 PM

Document Has Been Signed on 12/04/2024 03:38 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:ST. ANTHONY'S BOARD AND CAREFACILITY NUMBER:
374600449
ADMINISTRATOR/
DIRECTOR:		BESSIE PASCUALFACILITY TYPE:
740
ADDRESS:6533 PLAZA RIDGE ROADTELEPHONE:
(619) 470-4571
CITY:SAN DIEGOSTATE: CAZIP CODE:
92114
CAPACITY: 6CENSUS: 5DATE:
12/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:25 AM
MET WITH:Bessie Pascual, Licensee, and Blythe Pascual, Assistant AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced required Annual Inspection. The facility file was reviewed prior to the visit. LPA Lopez identified herself, was granted entry by caregiver Benachloe Sabio. LPA discussed the purpose of the visit with caregiver Sabio and Licensee Bessie Pascual who later arrived and joined the visit.

According to the facility’s license, there may be a maximum of six (6) residents in care, four (4) of whom may be non-ambulatory in rooms 1 & 5 in at any given time at the facility site. Facility is approved for 2 hospice residents. During today’s inspection, the facility’s current census is five (5) residents living at the facility. There were 2 residents present at the facility site during the inspection.

LPA, accompanied by Licensee Pascual, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary and mostly in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. Sink in bathroom #1 was observed to be leaking. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and activities.

The facility’s ambient internal temperature was comfortable and compliant, at 70 degrees Fahrenheit (F). Hot water temperature at taps accessible to clients were also compliant: Kitchen sink measured hot water at 109.9 degrees F; sink in restroom #1 delivered hot water at 109.9 degrees F; and sink in restroom #2 delivered hot water at 111.6 degrees F. LPA observed that there were cockroaches located in bathroom #1.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present. Cooking/dining equipment and utensils were present, and all safely stored. There were no toxic chemicals/poisons accessible to residents. Medications were properly labeled, as required, and stored in a locked cabinet which LPA inspected. The facility - maintained medication logs which LPA reviewed.

[CONTINUED ON LIC 809-C]
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: ST. ANTHONY'S BOARD AND CARE
FACILITY NUMBER: 374600449
VISIT DATE: 12/04/2024
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[CONTINUED FROM LIC 809]

No pools or bodies of water on the premises. Per licensee Pascual, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher was present (01) and serviced within the last 12 months. First aid kit were complete and readily accessible.

LPA spoke with staff and residents, and reviewed staff and resident records. During today’s visit there were 2 residents on the facility premise and three returned from their program during the visit. LPA interviews did not raise any licensing concerns. The files which LPA reviewed contained required documents. Confidential records were stored in a locked area. Required licensing postings were observed in a visible area of the facility.

There were deficiencies observed and cited during today's annual inspection and may be found on the LIC809-D page of this report.

An exit interview was conducted with Licensee Bessie Pascual and Assistant Administrator Blythe Pascual to whom a copy of this report along with the Licensee/Appeal Rights (LIC9058 03/22) were provided to Licensee Pascual at the conclusion of the visit. The signature below confirms the documents were received.

LPA requested Assistant Administrator Pascual and Licensee Pascual to submit a current Designation of Administrative Responsibility LIC 308, Personnel Report LIC 500, Emergency Disaster Plan LIC 610-E, and Residential Infection Control Plan LIC 9282 (6/23), to the licensing office within 10 business days. Forms are available at www.ccld.ca.gov.
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 12/04/2024 03:38 PM - It Cannot Be Edited


Created By: Carmen Lopez On 12/04/2024 at 02:25 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: 12/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(6)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs.

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 1 out of 2 bathroom sink was broken in bathroom #1 and was leaking which posed a potential personal rights risk to persons in care.
POC Due Date: 12/25/2024
Plan of Correction
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Licensee will be contracting a person to fix the leaking pipe and the fixtures to ensure the sink is in operating condition and will contact LPA upon completion by POC due date, 12/25/2024.
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above in 2 out of 5 residents did not have an updated Physician's Report in their file which posed a potential health risk to persons in care.
POC Due Date: 12/19/2024
Plan of Correction
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Licensee will be scheduling two appointments, one for each resident, and provide LPA with the appoinement scheduled information from their PCP by POC due date, 12/19/2024. Licensee will later submit the residents LIC602 once their PCP completes their form.
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:Robyn Clark
LICENSING EVALUATOR NAME:Carmen Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 12/04/2024 03:38 PM - It Cannot Be Edited


Created By: Carmen Lopez On 12/04/2024 at 02:25 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: 12/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(b)(1)
Medical Assessment
(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 5 residents did not have their TB clearance on file which posed a potential health risk to persons in care.
POC Due Date: 12/25/2024
Plan of Correction
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Licensee will be contacting the resident's PCP to obtain a copy of their last TB to keep on file and submit a copy to LPA by POC due date, 12/19/24.
Type B
Section Cited
CCR
80087(a)(1)
Facility shall take measures to keep the facility free of flies and other insects

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 1 out of 2 bathrooms had cockroaches which posed a potential personal rights risk to persons in care.
POC Due Date: 01/30/2025
Plan of Correction
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Licensee will contact their pest control company to increase their services every other week and submit their invoices for at least a total of 4 invoices, to LPA by POC due date, 01/30/24. Once the removal of the insects have been cleared, they will seal the crevice(s).
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:Robyn Clark
LICENSING EVALUATOR NAME:Carmen Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2024


LIC809 (FAS) - (06/04)
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