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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374600449
Report Date: 10/15/2025
Date Signed: 10/15/2025 07:04:59 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/08/2025 and conducted by Evaluator Carmen Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20251008160719
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:
10/15/2025
UNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Bessie Pascual, LicenseeTIME COMPLETED:
07:10 PM
ALLEGATION(S):
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- Staff did not ensure resident is spoken to in an appropriate manner
- Staff did not ensure medication is dispensed as prescribed
- Licensee did not ensure staff is in good health to perform assigned tasks
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced complaint visit to open a complaint investigation. While at the facility, LPA investigated and delivered findings regarding the above-mentioned allegations. LPA identified herself and was granted entry by Benachloe Sabio, caregiver. LPA stated the purpose of the visit and reviewed the findings of the complaint with Licensee Bessie Pascual.

The Department’s investigation consisted of interviews with staff and residents, and records review of relevant documents pertinent to this investigation. On October 8, 2025, it was said that staff did not speak with residents in an appropriate manner; staff did not ensure medication is dispensed as prescribed; and licensee did not ensure that staff is in good health to perform assigned tasks.

It was specifically alleged that staff scream at residents in care and licensee did not ensure that staff were in good health to perform assigned tasks. Interview with the residents #1, 2, and 4 confirmed that the staff #1 (S1) did scream at them while in their care.
(Continuation on LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 08-AS-20251008160719
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/15/2025
NARRATIVE
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According to R1, they had to tell S1 not to scream at resident #2 (R2) who is unable to defend themselves. R1 said that they informed the Licensee and their daughter. According to R2, they were able to understand the questions and answer them in small words and were able to articulate and scream how S1 would scream at them. While LPA spoke with them, they seemed in an altered state and their eyes started to tear up. LPA was able to inquire how they are currently being treated, and they were able to say they were being treated better. Resident #4 (R4) did confirm that S1 did yell at everyone. According to resident #3 (R3), they were treated fine and S1 did not yell at them. Resident #5 was unable to be interviewed as they were unable to hear well and would change the conversation when LPA asked them questions multiple times. According to staff #2 they confirmed S1 would yell at the residents. Staff and residents did confirm that S1 was hard of hearing which Licensee confirmed. Licensee did inform LPA that S1 was hard of hearing and had vision issues. LPA inquired if they had any PCP notes for the staff that indicated they had any issues with their hearing and they did not. Licensee said that when they had asked S1 about yelling at residents they had denied they yelled at them. S1 had informed Licensee that they were unable to hear. According to staff #3 and 4 (S3 and S4), they had not heard any staff yell at residents. According to S5 they had observed S1 being burnt out the last few weeks when they would speak to them but did not observe S1 yelling at residents.

It was specifically said that staff were unable to administer medications as prescribed. The facility was unable to provide a medication profile sheet for R1, but they did have a MAR from R1s pharmacy. The facility had just recently received their MAR but were using their own medication log. LPA was unable to obtain the accurate medications R1 was to take but was able to compare the medications to the pharmacy MAR and the facility MAR. There were discrepancies found during the review. The pharmacy MAR did not have three medications the facility had on their medication log and in R1s medications that are being administered. There was one medication that the bubble pack and the facility MAR had as a PRN, but the pharmacy log had the medication being administered two times daily. The pharmacy MAR had a medication that the facility MAR and the facility did not have.

Based on the Department’s investigation of the above-mentioned allegations and the evidence obtained during staff and resident interviews, and records reviewed, there is sufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegations are deemed to be substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC9099D.

The report was discussed, plan of correction was jointly developed, and an exit interview was conducted with Licensee Bessie Pascual. A copy of this report along with Licensee/Appeal Rights (LIC9058 3/22) were provided to Licensee Pascual at the conclusion of the visit. The signature below confirms the receipt of these documents.
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 08-AS-20251008160719
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/17/2025
Section Cited
CCR
87468.1(a)(1)
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Personal Rights of Resident in All Facilities (1) To be accorded dignity in their personal relationships with staff, residents, and other persons...
This requirement was not met as evidenced by:
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According to LIcensee, S1 is not currently working at this facility. This is deemed cleared during the visit.
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Based on the Departments investigation during interviews there was confirmation that staff #1 (S1) would yell at three of 5 residents in care which posed an potential risk to residents in care.
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Type B
10/17/2025
Section Cited
CCR
87411(f)
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Personnel Requirements - General: (f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks...this requirement was not met as evidenced by:
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Per the Licensee, S1 is no longer working at this facility. This is deemed cleared during the visit.
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Based on the Department's investigation, during staff and resident interviews, they confirmed that S1, had hearing and vision conditions that needed to be addressed which posed an potential risk to 5 of 5 residents 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.
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 08-AS-20251008160719
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/16/2025
Section Cited
CCR
87465(e)
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Incidential Medical and Dental: e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information... this requirement was not met as evidenced by:
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Licensee agreed to contact R1s pharmacy and obtain medication sheets for all their residents and schedule staff to obtain medication training by POC due date, 10/16/2025.
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Based on the Departments investigation during the records review, the facility did not maintain an accurate MAR for resident #1 (R1) of 5 residents in care which posed an immediate health risk to 1 of 5 residents 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.
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/08/2025 and conducted by Evaluator Carmen Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20251008160719

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:
10/15/2025
UNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Bessie Pascual, LicenseeTIME COMPLETED:
07:10 PM
ALLEGATION(S):
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2
3
4
5
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9
- Staff did not ensure residents personal property was safely secured
- Licensee did not ensure insect issue is being properly managed
- Staff did not ensure food of good quality is provided to residents in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced complaint visit to open a complaint investigation. While at the facility, LPA investigated and delivered findings regarding the above-mentioned allegations. LPA identified herself and was granted entry by Benachloe Sabio, caregiver. LPA stated the purpose of the visit and reviewed the findings of the complaint with Licensee Bessie Pascual.

The Department’s investigation consisted of interviews with staff and clients, records review of relevant documents pertinent to this investigation, and LPA observations. On October 8, 2025, it was said that staff did not ensure residents personal property was safely stored; licensee did not ensure insect issue is being properly managed; and staff did not ensure food of good quality is provided to residents in care.

It was specifically alleged that resident #1 (R1) had five hats that were taken by resident #4 (R4). According to R1, they had found their hats. Staff #2 (S2) had found their hats for them. R1 said they had mistaken it and that their hats were mixed in with their belongings.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 08-AS-20251008160719
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/15/2025
NARRATIVE
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They believed that R4 had taken them as they had previously taken their food items that are on the facility cub board. According to S2, they were informed that R1 had missing hats for a few days and decided to look for them alongside R1. S2 had found the hats in their assigned closet under their television and the rest behind their television. According to R1, nothing further was taken. R1 said that they keep their food items in their room, which LPA observed and confirmed.

According to R1 they had bug bites prior to the facility being tented. LPA inquired if they had any bites after they had returned and they denied having any new bug bites on them. LPA confirmed with staff #2 and Licensee that the facility had been tented within the last month, between 09/18 – 21/2025. Licensee said that they had to remove the pesticides from the facility as the bi-monthly services were inadequate and there were still bugs around. Licensee said that so far they had not see any bugs since their return.

It was specifically alleged that the food they only eat is a peanut butter and jelly sandwich with a salad for dinner. According to R1, they are fine with the food they eat at the facility. The Licensee recently took them to the store to purchase some food, snacks and hygiene products they wanted. They said that the food there is okay but better than the last place they lived. According to R2, they do like the food at the facility and had no issues with it. They like eating meatballs and spaghetti. According to R3, they liked the food especially pizza nights which they have weekly and eating pancakes. According to R4, they used to eat a lot of Filipino foods, but no longer eat that and currently eat cereals, hard boiled eggs, tea and coffee which is better than before. According to S2 and S3 they assist with meal preparation. S2 cooks the food and they attempt to make the meals that the residents prefer such as french toast, pancakes, coffee, tea, cereals, oatmeal, eggs, beef stew and other meals they prefer. LPA observed that the facility did have two refrigerators and pantry which held sufficient food items.

Based on the Department’s investigation of the above-mentioned allegations and the evidence obtained during staff and outside source interviews, records reviewed, and LPA observations, there is insufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegations are deemed to be unsubstantiated.

The report was discussed, and an exit interview was conducted with Licensee Bessie Pascual. A copy of this report along with Licensee/Appeal Rights (LIC9058 3/22) were provided to Licensee Pascual at the conclusion of the visit. The signature below confirms the receipt of these documents.
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6