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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508550
Report Date: 11/18/2023
Date Signed: 11/18/2023 01:15:48 PM


Document Has Been Signed on 11/18/2023 01:15 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: 3DATE:
11/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator Teofila OueisTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct an annual/required inspection. LPA met with Administrator, Teofila Oueis and explained the purpose of the visit. Census: 3

This is a single-story facility with 6 resident bedrooms, 1 staff bedroom, 5 half bathrooms, and 2 full bathrooms. LPA Lund & Administrator, Teofila Oueis toured/inspected the facility and grounds. No accessible bodies of water or fire safety hazards observed. 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.

LPA toured the kitchen and observed the locked medication cabinet; LPA observed the locked cabinet with toxins and knives located under the sink. 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.

No deficiencies were cited during the visit and report left.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2023
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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