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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294209
Report Date: 08/23/2021
Date Signed: 08/23/2021 04:51:54 PM

Document Has Been Signed on 08/23/2021 04:51 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, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:SAINT ANTHONY'S CARE HOME FOR THE ELDERLYFACILITY NUMBER:
435294209
ADMINISTRATOR:CASTILLEJO, EUGENE J.FACILITY TYPE:
740
ADDRESS:3258 EVCO COURTTELEPHONE:
(408) 708-4758
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY: 6CENSUS: 4DATE:
08/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Eugene Castillejo (ADM)TIME COMPLETED:
01:41 PM
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Licensing Program Analyst Steve Chang conducted an unannounced Annual Inspection today, and met with administrator (ADM) Eugene Castillejo. Upon arrival at the facility, staff Adelina Hufana(S1) took LPA body temperature, and asked if LPA had the symptoms of COVID, then checked in LPA in the visitor log book.

The rosters of residents and staff were obtained. LPA toured the facility with S1 inside out. There are 3 shared resident bedrooms, and one staff live-in bedroom in facility. There are 2 bathrooms in facility. LPA observed the COVID-19 posters in the facility. LPA observed all the trash cans were with covers. LPA observed the beds in the resident rooms were 6 feet apart. LPA observed the medication cabinet was locked. LPA inspected the food supplies. The 2 day perishable food and 7 day nonperishable food were sufficient. LPA observed another staff Evelyn Pelobello (S2) in the facility. LPA observed 3 residents (R1- R3) in the facility. S1 stated the resident Julia Droze (R4) was in hospital.

LPA discussed and reviewed LIC808 with ADM. ADM stated all the staff and residents are fully vaccinated.

No citation were issued during today's inspection. Exit interview conducted with ADM. This report was provided to ADM to review and to sign. A copy of this report was emailed to ADM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2021
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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