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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601391
Report Date: 03/11/2026
Date Signed: 03/11/2026 01:10:45 PM

Document Has Been Signed on 03/11/2026 01:10 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/
DIRECTOR:		WHITE, RACHEL OFACILITY TYPE:
740
ADDRESS:2640 MALLARD COURTTELEPHONE:
(510) 972-0332
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 1DATE:
03/11/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Josielyn Ranosa, Caregiver TIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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On 03/11/2026 at 9:00 AM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct a 1-Year Annual Required inspection. LPA met with Care Staff, Josielyn Ranosa, and explained the purpose of the visit. Administrator Rachel White was not available, however CO- Administrator Faith Oribello gave authorization on the phone for Care Staff to sign the report. Administrator certificate is current (7022033740 exp: 04/16/26). The facility’s fire clearance was approved for six (6), all may be non-ambulatory, and three (3) hospice waiver.

LPA toured the 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, of 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 that lighting in all rooms is adequate for the comfort and safety of the residents. The temperature of the hot water in the residents’ shared bathroom was measured at 115.9°F. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week's supply of nonperishable and 2 days' supply of perishable foods.

Report Continued on LIC 809c…

NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Kelly Nguyen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2026
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 9
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 03/11/2026 01:10 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 03/11/2026 at 12:03 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: 03/11/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)(1)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. (1) Disinfectants, cleaning solutions, and poisonous substances shall be stored in areas separate from food supplies as specified in Section 87555, General Food Service Requirements.

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 unlock liquid detergent underneath the sink, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/12/2026
Plan of Correction
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Administrator immediately removed the unlocked liquid detergent and secured it in a locked cabinet inaccessible to residents. Administrator will ensure all cleaning supplies and hazardous items are kept locked at all times. Administrator will conduct staff training on proper storage of hazardous items and implement routine checks to ensure ongoing compliance. Proof of correction will be submitted to CCLD by the POC due date on 3/18/26.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Kelly Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2026


LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 03/11/2026 01:10 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 03/11/2026 at 12:03 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: 03/11/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

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 LPA observed a cockroach crawling on the wall and a dead cockroach inside the refrigerator which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2026
Plan of Correction
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Administrator immediately cleaned and sanitized the affected areas and removed the dead cockroach from the refrigerator. Licensee will contact a licensed pest control service and implement routine pest control and cleaning procedures to maintain a sanitary environment. Proof of correction will be submitted to CCLD by the POC due date.
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

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 LPA observed that three sliding door net screen ripped which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2026
Plan of Correction
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Administrator will repair or replace the three ripped sliding door screens to ensure they are in good repair. Administrator will conduct routine facility checks to ensure all screens remain in good condition. Proof of correction will be submitted to CCLD by the POC due 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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Kelly Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2026


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 03/11/2026 01:10 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 03/11/2026 at 12:03 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: 03/11/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(23)
General Food Service Requirements
(23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures.

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 by having moldy food inside the refrigerator which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2026
Plan of Correction
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Administrator immediately discarded the moldy food and cleaned and sanitized the refrigerator. Administrator will ensure staff routinely check and remove expired or spoiled food to maintain sanitary food storage. Proof of correction will be submitted to CCLD by the POC due date.
Type B
Section Cited
CCR
87555(b)(27)
General Food Service Requirements
(27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

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 by LPA observed a cockroach crawling on the wall, floor, and a dead cockroach inside/ outside the refrigerator which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2026
Plan of Correction
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Administrator immediately cleaned and sanitized the affected areas and removed the dead cockroach. Licensee will arrange pest control service and implement routine cleaning and monitoring to maintain a sanitary, pest-free environment. Proof of correction will be submitted to CCLD by the POC due 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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Kelly Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2026


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 03/11/2026 01:10 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 03/11/2026 at 12:03 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: 03/11/2026

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 LPA file review that resident PRNs are not documented on the Medication Administration Record (MAR), which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2026
Plan of Correction
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Administrator will ensure all PRN medications are documented on the Medication Administration Record (MAR). Administrator will review resident medication records and train staff on proper MAR documentation to ensure ongoing compliance. Proof of correction will be submitted to CCLD by the POC due 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 onducted a file review of the resident's medication, which is not listed on MAR, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2026
Plan of Correction
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Administrator will review resident medication records and ensure all medications are accurately listed on the Medication Administration Record (MAR). Administrator will train staff on proper MAR documentation and conduct routine audits to ensure ongoing compliance. Proof of correction will be submitted to CCLD by the POC due 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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Kelly Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2026


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 03/11/2026 01:10 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 03/11/2026 at 12:03 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: 03/11/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(d)(3)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to 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: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.

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 LPA conducted a file review of the resident's file, and the resident had no record of PRN. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2026
Plan of Correction
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Administrator will review resident records and ensure all PRN medications and orders are properly documented in the resident’s file. Administrator will train staff on proper documentation and conduct routine record reviews to ensure ongoing compliance. Proof of correction will be submitted to CCLD by the POC due 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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Kelly Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2026


LIC809 (FAS) - (06/04)
Page: 7 of 9
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: 03/11/2026
NARRATIVE
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Report Continued…

Carbon monoxide detectors were in operation during the visit. The fire extinguisher was last serviced on 09/8/2025. Emergency Disaster Plan was last posted on 1/14/2026. The first aid kit was observed to be complete. The emergency disaster drill was last conducted on 01/15/2026. Liability insurance dated: 3/8/25 to 3/8/26

LPA reviewed 1 resident's records. LPA reviewed 4 staff records, and all are associated with the facility. LPA reviewed a sample of residents’ medications.

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING THE VISIT:

· At 10:15 am, LPA conducted a file review of resident PRNs that were not documented on the Medication Administration Record (MAR).


· At 10:17 am, LPA conducted a file review of the resident's file, and the resident had no record of PRN.

· At 10:20 am, LPA conducted a file review of the resident's medication, which is not listed on MAR.





Report continue on LIC 809...

NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Kelly Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2026
LIC809 (FAS) - (06/04)
Page: 8 of 9
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: 03/11/2026
NARRATIVE
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Report continued...

· At 10:30 am, LPA observed a cockroach crawling on the wall, floor, and a dead cockroach inside/ outside the refrigerator


· At 10:35 am, LPA observed expired food and moldy food inside the refrigerator


· At 11:25 am, LPA observed liquid detergent underneath the sink


· At 11:35 am, LPA observed that three sliding door net screen ripped



- A repeat of 87465(a)(6) and 87465(c)(2) is issue on today date in the amount of $250 + $250 = $500.

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

An exit interview was conducted with the staff. Appeal Rights and a copy of this report are provided along with LIC421FC.

NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Kelly Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2026
LIC809 (FAS) - (06/04)
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