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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601391
Report Date: 03/20/2025
Date Signed: 03/20/2025 06:25:25 PM

Document Has Been Signed on 03/20/2025 06:25 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:ST. THERESE CARE HOME IIFACILITY NUMBER:
015601391
ADMINISTRATOR/
DIRECTOR:		WHITE, RACHEL OFACILITY TYPE:
740
ADDRESS:2640 MALLARD COURTTELEPHONE:
(510) 972-0332
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 5DATE:
03/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:55 PM
MET WITH:Alvin Galang, Direct Care Staff TIME VISIT/
INSPECTION COMPLETED:
06:40 PM
NARRATIVE
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On 03/20/2025 at 2:55 PM, Licensing Program Analysts (LPAs) P. Manalo and K.Nguyen arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Care Staff, Alvin Galang, and explained the purpose of the visit. Administrator, Rachel White, gave authorization on the phone for Care Staff to sign the report. Administrator certificate is current. The facility’s fire clearance was approved for six (6) all may be non-ambulatory and three (3) hospice waiver.

LPAs toured facility with staff inside and out including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 5 total bedrooms which 4 bedrooms are occupied by the residents and 1 bedroom is occupied by staff. There are no bodies of water observed. A comfortable temperature is maintained at 72 degrees Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 110.6 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods.

Carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 01/22/2025. Emergency Disaster Plan was last posted on 03/28/2024. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 01/20/2025.

At 3:03 PM, LPA reviewed 5 residents records. At 03:28 PM, LPAs reviewed 4 staff records and all are associated to the facility. At 5:00 PM, LPA reviewed a sample of resident’s medications.

Continue to LIC809-C...
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2025
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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Document Has Been Signed on 03/20/2025 06:25 PM - It Cannot Be Edited


Created By: Patricia Manalo On 03/20/2025 at 05:57 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: 03/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in having unlocked wound care saline, prescribed thick-it, Halls, Isopropyl Alcohol, etc. accessible to residents in care which poses an immediate health and safety risk to persons in care.
POC Due Date: 03/21/2025
Plan of Correction
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The Administrator agrees to lock the items, have a Medication In-Service Training, and send proof to CCLD by POC date.
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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/20/2025 06:25 PM - It Cannot Be Edited


Created By: Patricia Manalo On 03/20/2025 at 05:57 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: 03/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

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 residents' PRN that are not documented on the Medication Administration Record (MAR) which poses a potential health and safety risk to persons in care.
POC Due Date: 03/28/2025
Plan of Correction
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4
Administrator agrees to submit proof of the PRN medications documented on the MAR by POC date.
Type B
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

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 residents' medication that are not listed on MAR which poses a potential health and safety risk to persons in care.
POC Due Date: 03/28/2025
Plan of Correction
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Administrator agrees to look through all the MAR, ensure all the medications are correctly documented, and send proof 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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2025


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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ST. THERESE CARE HOME II
FACILITY NUMBER: 015601391
VISIT DATE: 03/20/2025
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Continue from LIC809...

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:
  • At 4:00 PM, LPAs observed wound care saline, prescribed thick-it, Halls, Isopropyl Alcohol, etc. accessible to residents in care.
  • At 5:15pm LPAs observed residents PRN are not documented on the Medication Administration Record (MAR).
  • At 5:20PM LPAs observed resident medication are not listed on MAR.


The Facility was cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted with Staff. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025
LIC809 (FAS) - (06/04)
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