<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600449
Report Date: 12/05/2025
Date Signed: 12/05/2025 07:11:11 PM

Document Has Been Signed on 12/05/2025 07:11 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:
12/05/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:25 PM
MET WITH:Benachloe Sabio, CaregiverTIME VISIT/
INSPECTION COMPLETED:
06:20 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced required Annual Inspection. The facility file was reviewed prior to the visit. LPA identified herself and was granted entry by caregiver Benachloe Sabio. LPA discussed the purpose of the visit with caregiver Sabio.

According to the facility’s license, there may be a maximum of 6 residents, 4 of whom may be non-ambulatory in approved bedrooms 1 & 5 at any given time at the facility site. The facility is approved for 2 hospice residents. During today’s inspection, the facility’s current census is 5 residents living at the facility. There were no residents present at the facility site during the inspection.

LPA inspected the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and 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. 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.

There were at least 2 days of perishable food, and at least 7 days of non-perishable food present. Cooking, dining equipment, and utensils were present and all safely stored. There were no toxic chemicals or 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]
NAME OF LICENSING PROGRAM MANAGER: Robyn Clark
NAME OF LICENSING PROGRAM ANALYST: Carmen Lopez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2025
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 13
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)
Page: 2 of 13
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: 12/05/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
[CONTINUED FROM LIC 809]

No pools or bodies of water on the premises. There is was a fireplace which was not in use and inaccessible to clients. Per caregiver Sabio, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and the facility telephone were all working. A fire extinguisher was present (01) but needed to be serviced within the last 12 months. A first aid kit was complete and readily accessible.

LPA spoke with a staff and resident, and reviewed staff and resident records. LPA interviews did not raise any licensing concerns. The files that LPA reviewed contained the 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, as well as Technical Violations (TV) and Technical Advisories (TA) issued, which may be found within this report.

An exit interview was conducted with caregiver Benachloe Sabio, to whom a copy of this report, along with the Licensee/Appeal Rights (LIC9058 03/22), were provided at the conclusion of the visit. The signature below confirms that the documents were received.

LPA requested caregiver Sabio to submit a current Designation of Administrative Responsibility (LIC 308), Personnel Report (LIC 500), and Emergency Disaster Plan (LIC610-E) to the licensing office within 10 business days. Forms are available at www.ccld.ca.gov.
NAME OF LICENSING PROGRAM MANAGER: Robyn Clark
NAME OF LICENSING PROGRAM ANALYST: Carmen Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2025
LIC809 (FAS) - (06/04)
Page: 3 of 13
Document Has Been Signed on 12/05/2025 07:11 PM - It Cannot Be Edited


Created By: Carmen Lopez On 12/05/2025 at 05:35 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: 12/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87202(a)
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:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based onobservation, the licensee did not comply with the section cited above in 1 of 1 fire extinguishers were not serviced within the last 12 months which posed a potential safety risk to persons in care.
POC Due Date: 01/02/2026
Plan of Correction
1
2
3
4
Facility agreed to obtain current fire extinguisher and send LPA current tags via email by POC due date, 01/02/2026.
Type B
Section Cited
HSC
1569.69(a)(2)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 2 of 2 staff did not have training records within their file which posed a potential personal rights risk to persons in care.
POC Due Date: 01/02/2026
Plan of Correction
1
2
3
4
Facility agreed to submit staff training to LPA by POC due date, 01/02/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Robyn Clark
NAME OF LICENSING PROGRAM MANAGER:
Carmen Lopez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2025


LIC809 (FAS) - (06/04)
Page: 4 of 13
Document Has Been Signed on 12/05/2025 07:11 PM - It Cannot Be Edited


Created By: Carmen Lopez On 12/05/2025 at 05:35 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: 12/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 2 out of 5 residents [R4 and R5] did not have an updated Physician's Report on file which posed a potential rights risk to persons in care.
POC Due Date: 01/02/2026
Plan of Correction
1
2
3
4
Facility agreed to schedule a medical appointment for resident to obtain their LIC602, and email LPA with the schedued date by POC due date, 01/02/2026.
Type B
Section Cited
CCR
87507(c)
Admission Agreements
(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in1 out of 5 residents did not have an admission agreement on file which posed a potential personal rights risk to persons in care.
POC Due Date: 01/02/2026
Plan of Correction
1
2
3
4
Facility agreed to have the resident/POA sign for the residents admission agreement and submit to LPA by POC due date, 01/02/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Robyn Clark
NAME OF LICENSING PROGRAM MANAGER:
Carmen Lopez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2025


LIC809 (FAS) - (06/04)
Page: 5 of 13
Document Has Been Signed on 12/05/2025 07:11 PM - It Cannot Be Edited


Created By: Carmen Lopez On 12/05/2025 at 05:35 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: 12/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(e)(2)
Other Provisions
(e) A facility shall have all of the following information readily available to facility staff during an emergency: (2) An appraisal of resident needs and services plan for each resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 3 of 5 residents did not have an updated needs and service plan [R2, R3, and R4] which posed a potential personal rights risk to persons in care.
POC Due Date: 01/02/2026
Plan of Correction
1
2
3
4
Facility agreed to submit updated needs and service plans for R2, R3, and R4, via email to LPA by POC due date, 01/02/2026.
Type B
Section Cited
CCR
80065(g)(1)
Personnel Requirements: ...good physical health shall be verified by a health screening, including a test for tuberculosis...

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 2 staff did not have a TB on file which posed a potential health, and personal rights risk to persons in care.
POC Due Date: 01/02/2026
Plan of Correction
1
2
3
4
The facility sgreed to obtain staff TB and submit to LPA via email by POC due date, 01/02/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Robyn Clark
NAME OF LICENSING PROGRAM MANAGER:
Carmen Lopez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2025


LIC809 (FAS) - (06/04)
Page: 6 of 13