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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601391
Report Date: 04/28/2022
Date Signed: 04/28/2022 11:59:41 AM


Document Has Been Signed on 04/28/2022 11:59 AM - 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:ST. THERESE CARE HOME IIFACILITY NUMBER:
015601391
ADMINISTRATOR:BANTAY, MARIAFACILITY TYPE:
740
ADDRESS:2640 MALLARD COURTTELEPHONE:
(510) 324-6444
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:6CENSUS: 4DATE:
04/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Alvin Galang, CaregiverTIME COMPLETED:
12:10 PM
NARRATIVE
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On 4/28/2022 at 10:00AM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA met with Alvin Galang, Caregiver and explained the purpose of the visit. House Manager arrived at 10:40AM.

Upon entry, LPA's temperature was checked. LPA observed screening station that contained hand sanitizer, masks and COVID signage. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, kitchen, garage and backyard. LPA observed cough etiquette, physical distancing signs posted, and hand sanitizer dispensers in the common areas. All hand washing stations were equipped with soap and paper towel. Hot water temperature in the shared clients’ bathroom was measured at 106.7 degree Fahrenheit. Fire extinguisher was last serviced on 11/21/2021.

During record review, LPA observed facility has a copy of Mitigation Plan on file. LPA observed PPE, food, and paper supplies are sufficient.

The following forms are to be updated and submitted to CCLD by 5/05/2022:

-LIC500 Personnel Report
-LIC308 Designation of Administrative Responsibility

Continued on LIC9099C
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022
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 5


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ST. THERESE CARE HOME II
FACILITY NUMBER: 015601391
VISIT DATE: 04/28/2022
NARRATIVE
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Continued from LIC9099.

-LIC610E Emergency Disaster Plan
-An updated copy of Administrator certificate

The following deficiencies were observed:

-At 10:10AM, LPA observed Staff 2 (S2) and Staff 3 (S3) not associated to the facility.
-At 10:20AM, LPA observed unlocked garage door with detergent and fabuloso sitting on counter.

An immediate civil penalty of $600 was assessed.

The following deficiencies were observed (see LIC809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 04/28/2022 11:59 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: ST. THERESE CARE HOME II
FACILITY NUMBER: 015601391

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(g)(1)

87411 Personnel Requirements- General (g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall:
(1) Obtain a California clearance or a criminal record exemption as required by law or Department regulations or

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 having S2 and S3 associated to the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/29/2022
Plan of Correction
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House Manager agreed to submit an LIC9182 and Identification for both S2 and S3 to associate staff to CCLD by POC date. House manager submitted LIC9182 and Identficiation for both S2 and S3 to LPA during visit. Deficiency cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4

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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 04/28/2022 11:59 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: ST. THERESE CARE HOME II
FACILITY NUMBER: 015601391

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(f)(2)
87705 Care of persons with dementia (f) The following shall be stored inaccessible to residents with dementia:
(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
This requirement is not met as evidenced by:
This requirement was not met as evidence by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having detergent and fabuloso accessible which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/01/2022
Plan of Correction
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House Manager agreed to lock detergent and fabuloso in locked cabinet in garage and take photo to submit to CCLD by POC date. House manager locked detergent and fabuloso in locked cabinet in garage during inspection. Deficiency cleared during inspection.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4

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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5