015601391-1-28-2023-15-AS-LHAL-CNHVZK-20230128155252

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015601391
Report Date: 01/28/2023
Date Signed: 01/28/2023 03:53:24 PM

Document Has Been Signed on 01/28/2023 03:53 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	ST. THERESE CARE HOME II		FACILITY NUMBER:	015601391
ADMINISTRATOR:	BANTAY, MARIA		FACILITY TYPE:	740
ADDRESS:	2640 MALLARD COURT		TELEPHONE:	(510) 324-6444
CITY:	UNION CITY	STATE: CA	ZIP CODE:	94587
CAPACITY:	6	CENSUS: 5	DATE:	01/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:40 PM
MET WITH:	Bennet Flores, Caregiver		TIME COMPLETED:	04:05 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	On 1/28/2023 at 12:40PM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA met with Bennet Flores Caregiver and explained the purpose of the visit. LPA spoke with Administrator Maria Bantay, via telephone at 1:20PM and was given approval for caregiver to sign documents. Upon entry, LPA's temperature was not checked. LPA observed screening station and COVID-19 signs were posted on the front door. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, back yard, kitchen, and garage. LPA observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap and paper towel. Hand washing posters were posted at hand washing stations. Hot water temperature in the shared clients’ bathroom was measured at 116.5 degrees Fahrenheit. Fire extinguisher last serviced on 10/06/21. During record review, LPA observed visitors sign-in log. LPA observed facility has a copy of the mitigation plan on file. LPA observed paper supplies are sufficient. Continued on LIC809C.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2023

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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ST. THERESE CARE HOME II	FACILITY NUMBER: 015601391
	VISIT DATE: 01/28/2023

NARRATIVE

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Continued from LIC809.

LPA requested the following documents to be submitted to CCLD by 2/6/2023.

Personnel Record (LIC500).
Updated emergency disaster plan (LIC610E).
Facility roster

LPA observed the following deficiencies:

-At 12:45PM, LPA observed steak knife, and two pair of scissors drying in hospital pitcher on kitchen counter.

-At 12:55PM, LPA observed unlocked kitchen drawer with key containing knives.

-At 12:58PM, LPA observed Day Quil and other medication in unlocked kitchen pantry with key, Day Quil and congestion medication in refrigerator, and Miralex and Meta Mucil sitting on kitchen counter.

-At 1:00PM, LPA observed fire extinguisher was last services 10/6/2021.

-At 1:05PM, LPA observed facility did not have a supply of 7-day non-perishables (canned goods and meat) and 2-day perishable (observed 6 bananas, 1 apple, and 5 oranges)

-At 1:10PM, LPA observed cough medication sitting on chest of drawers in bedroom #1.

-At 1:15PM, LPA observed bed in bedroom #2 was blocking exit (patio door).

Continued on LIC809C.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2023

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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ST. THERESE CARE HOME II	FACILITY NUMBER: 015601391
	VISIT DATE: 01/28/2023

NARRATIVE

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Continued from LIC809C.

-At 1:20PM, LPA observed cardboard, 3 chair patio chair cushions, and toilet seat on left side of house.

-At 1:30PM, LPA observed R3 did not have a doctor's order for the hospital bed.

An immediate civil penalty of $500.00 will to assessed on today's date.

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. A $500.00 civil penalty is assessed for deficiency # 87203. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report, LIC421IM, and appeal rights provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/28/2023 03:53 PM - 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: 01/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(1)

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having knives and scissors locked away and inaccessible which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/29/2023
	Plan of Correction
1 2 3 4	Caregiver placed knives and scissors in kitchen drawer and locked kitchen drawer during inspection. Deficiency cleared during visit.

Type A

Section Cited

CCR

87705(f)(2)

f) The following shall be stored inaccessible to residents with dementia: (1) 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:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having medication locked away and inaccessible which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/29/2023
	Plan of Correction
1 2 3 4	Caregiver locked medication in closet, making medication inaccessible to residents during inspection. Deficiency cleared during visit.

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 Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/28/2023 03:53 PM - 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: 01/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87203

87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in not having the fire extinguisher serviced or purchasing a new fire extinguisher, and blocking an exit door with a resident's bed which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/29/2023
	Plan of Correction
1 2 3 4	Administrator agreed to have fire extinguisher serviced or replace it with a new one and submit photo to CCLD by 2/6/2023. And rearrange beds in bedroom #2 to unblock exit and submit photos of rearranged room to CCLD by POC date 1/29/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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 Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/28/2023 03:53 PM - 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: 01/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(26)

87555 General Food Service Requirements (b) The following food service requirements shall apply: 26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having 7-day of non-perishables and 2-day perishable foods for residents which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/06/2023
	Plan of Correction
1 2 3 4	Administrator agreed to purchase food and submit photos of food and receipts to CCLD by POC date.

Type B

Section Cited

CCR

87307(d)(6)

87307 Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having passageway on left side of house free of obstruction which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/06/2023
	Plan of Correction
1 2 3 4	Administrator agreed to remove cardboard, toilet, cushions, and any other debris from side of house and submit a photo to CCLD by POC date.

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 Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2023

LIC809 (FAS) - (06/04)

Page: 8 of 9

Document Has Been Signed on 01/28/2023 03:53 PM - 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: 01/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87608(a)(3)

87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review) the licensee did not comply with the section cited above in having a doctor's order for R3's bed which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/06/2023
	Plan of Correction
1 2 3 4	Administrator agreed to obtain a doctor's order for R3's bed and submit a photo copy to CCLD by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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 Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2023

LIC809 (FAS) - (06/04)

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