<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508550
Report Date: 03/28/2022
Date Signed: 03/28/2022 03:17:07 PM


Document Has Been Signed on 03/28/2022 03:17 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:RETIREMENT PLUS OF SAN CARLOSFACILITY NUMBER:
410508550
ADMINISTRATOR:TEOFILA C OUEISFACILITY TYPE:
740
ADDRESS:612 CHESTNUT STREETTELEPHONE:
(650) 593-4777
CITY:SAN CARLOSSTATE: CAZIP CODE:
94070
CAPACITY:6CENSUS: 4DATE:
03/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator, Teofila OueisTIME COMPLETED:
03:30 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 March 28, 2022, at 2:00pm, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual inspection. Upon arrival, LPA did not observe COVID signage posted at the front door. LPA met with Administrator, Teofila Oueis and explained the purpose of the visit. LPA was not screened at entry point and Administrator was unable to provide LPA screening log documentation for visitors. This is a single story facility with 6 resident bedrooms, 1 staff bedroom, 5 half bathrooms, and 2 full bathrooms.

LPA toured the facility and grounds with the Administrator. No accessible bodies of water or fire safety hazards observed. Administrator was unable to provide a screening log documentation for staff and residents. LPA observed the bathrooms, all were equipped with paper-towels, liquid soap and hand-washing sign. LPA advised Administrator to ensure all trash cans have a lid. LPA observed the 6 resident rooms. According to the Administrator, all rooms are private rooms and 2 of the rooms are currently vacant at this time.

LPA toured the kitchen and observed the locked medication cabinet, however LPA observed the unlocked cabinet with toxins and knives located under the sink. Administrator locked the sharps and toxin cabinet during the visit. LPA observed 2 day perishable and 7 day non-perishable present. LPA observed the kitchen to be equipped with a covered trash can, liquid soap, and paper towels.

A comfortable temperature is maintained, lighting is sufficient for comfort. First aid kit was observed to be completed. Extra linen was observed to be present. Administrator was able to show LPA 30-day PPE supply.

CONTINUE TO 809C
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2022
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 4


Document Has Been Signed on 03/28/2022 03:17 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: RETIREMENT PLUS OF SAN CARLOS
FACILITY NUMBER: 410508550

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/29/2022
Section Cited

1
2
3
4
5
6
7
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).

Violation of this regulation is not met as evidence by:
8
9
10
11
12
13
14
Based on LPA's observation, during facility inspection LPA found that knives are stored in an area of the kitchen that is not secured under lock and key.
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: RETIREMENT PLUS OF SAN CARLOS
FACILITY NUMBER: 410508550
VISIT DATE: 03/28/2022
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
26
27
28
29
30
31
32
LPA requests the following forms to be sent to CCLD by 4/4/22:
  • LIC308 Designation of Administrative Responsibility
  • LIC500 Personnel Report
  • Administrator Certificate
  • LIC610D Emergency Disaster Plan

Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 809D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with the Administrator; a copy is provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4