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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601391
Report Date: 08/04/2023
Date Signed: 08/04/2023 01:35:10 PM

Document Has Been Signed on 08/04/2023 01:35 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 IIFACILITY NUMBER:
015601391
ADMINISTRATOR:WHITE, RACHEL OFACILITY TYPE:
740
ADDRESS:2640 MALLARD COURTTELEPHONE:
(510) 972-0332
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 4DATE:
08/04/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:TIME COMPLETED:
01:45 PM
NARRATIVE
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While LPA J. Clancy-Czuleger conducted a complaint investigation (15-AS-20230228093307) on 08/04/2023 LPA observed the following deficiencies

Based on interviews and observations staff is sleeping in common area including the living room and the kitchen. During interviews with staff, they stated that three staff sleeps in the kitchen and/or living room on fold up cot mattresses that are stored in the staff room where the fourth staff member sleeps.

While doing a walk through of the facility LPA observed that all five beds in the home have some form of bed rail. R1 and R2 are on hospice and are permitted to have bed rails. R3 is not on hospice and does not have doctors’ orders for bed rails but has full bed rails. R4 does not have doctor’s order for a bed rail and has it written in on an unsigned physician’s report.


The Facility was cited, and citations can be found on the LIC 809-D. Exit interview conducted. Appeal Rights and a copy of this report provided. Exit interview conducted.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE: DATE: 08/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2023
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 2
Document Has Been Signed on 08/04/2023 01:35 PM - It Cannot Be Edited


Created By: Jill Clancy-Czuleger On 08/04/2023 at 12:21 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
, 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: 08/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/07/2023
Section Cited

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Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. This requirement is not met as evidenced by
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Based on LPA's observation licensee did not comply with the section cited above by allowing staff to sleep on a mattress (that's stored in the garage) in the living room common area. Which poses a potential health and safety risk to residents.
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Type A
08/11/2023
Section Cited

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(5) Under no circumstances shall postural supports include ... Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care ...This requirement is not met as evidenced by
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Based on LPA's observation licensee did not comply with the section cited above by having
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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.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2023


LIC809 (FAS) - (06/04)
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