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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508550
Report Date: 12/27/2024
Date Signed: 12/27/2024 04:07:40 PM

Document Has Been Signed on 12/27/2024 04:07 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:RETIREMENT PLUS OF SAN CARLOSFACILITY NUMBER:
410508550
ADMINISTRATOR/
DIRECTOR:		TEOFILA C OUEISFACILITY TYPE:
740
ADDRESS:612 CHESTNUT STREETTELEPHONE:
(650) 593-4777
CITY:SAN CARLOSSTATE: CAZIP CODE:
94070
CAPACITY: 6CENSUS: 3DATE:
12/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:50 PM
MET WITH:Teofila Oueis, Administrator TIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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On 12/27/2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility at 12:50 PM to conduct the Annual 1-year required inspection. LPA Calandra was greeted by Teofila Oueis, Administrator and explained the purpose of the visit.

During the visit, LPA observed 1 resident in the living room watching television, 1 resident in bed asleep, and a third resident eating lunch in their room.

LPA toured the physical plant. This is a 1-story building with 7 bedrooms (6 bedrooms for residents and 1 for staff), 2 bathrooms, kitchen, office, back and front yards, sunroom, living room, and dining room. All bedrooms had the required furniture and sufficient lighting. The facility was maintained at a comfortable temperature. Per interview with the Administrator, the facility's fire alarms are connected directly to the fire department. The fire alarm panel was observed to be in working order. The facility had the required carbon monoxide detectors which were observed to be in working order. The facility had the required 7 days of non perishables and 2 days of perishables on hand. No food was expired.

All sharp objects, detergents, poisons, etc. were observed to be locked and in-accessible to persons in care.
LPA Calandra reviewed 3 resident files and 4 staff files. All were observed to be complete.

A review of Centrally stored medications indicated that medications for residents were properly labeled with instructions on dosage and times of day and matched the Centrally Stored Medication records kept at the facility.

LPA Calandra requested the following documents be sent to CCLD by 1/3/2024:
  • Current LIC 500
  • Liability Insurance

Deficiencies are cited under the California Code of Regulations, Title 22. Failure to correct the deficiencies by the due date may result in civil penalties

An exit interview was conducted. This report was reviewed with Teofila Oueis, Administrator and a copy of the report along with Appeal Rights left at the facility.

SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2024
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 6
Document Has Been Signed on 12/27/2024 04:07 PM - It Cannot Be Edited


Created By: John Calandra On 12/27/2024 at 03:25 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
, 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: 12/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, no staff have active CPR and first aid training, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/28/2024
Plan of Correction
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Administrator to arrange for CPR and first aid training for staff and submit proof that training is scheduled and proof of completion to CCLD
Section Cited
Deficient Practice Statement
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4
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:Andrea Medlin
LICENSING EVALUATOR NAME:John Calandra
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2024


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 12/27/2024 04:07 PM - It Cannot Be Edited


Created By: John Calandra On 12/27/2024 at 03:25 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
, 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: 12/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review of personnel records, S1 started in March 2020 and per the Health Screening Report, S1's TB results were in 2014, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/17/2025
Plan of Correction
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Administrator to have S1 schedule a TB exam and submit updated Health Screening Report or Chest X-ray results 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.
SUPERVISOR'S NAME:Andrea Medlin
LICENSING EVALUATOR NAME:John Calandra
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 12/27/2024 04:07 PM - It Cannot Be Edited


Created By: John Calandra On 12/27/2024 at 03:25 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
, 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: 12/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(6)
Personnel Requirements - General
(6) The licensee shall maintain documentation pertaining to staff training in the personnel records, as specified in Section 87412(c)(2). For on-the-job training, documentation shall consist of a statement or notation, made by the trainer, of the content covered in the training. Each item of documentation shall include a notation that indicates which of the criteria of Section 87411(c)(3) is met by the trainer.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview of Administrator, no training records were available to be reviewed by the LPA for S1, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/17/2025
Plan of Correction
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Administrator to submit documentation pertaining to staff training, including topics of training, dates of trainings, and logs showing which employees attended trainings as well as information such as qualification of the trainer and contact information for the trainer by the POC due date.
Type B
Section Cited
HSC
1569.696(a)
Other Provisions
(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, S1 has not received training on postural supports, restricted conditions, and hospice care which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/17/2025
Plan of Correction
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Administrator to submit proof that S1 has received training on postural supports, restricted conditions 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.
SUPERVISOR'S NAME:Andrea Medlin
LICENSING EVALUATOR NAME:John Calandra
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 12/27/2024 04:07 PM - It Cannot Be Edited


Created By: John Calandra On 12/27/2024 at 03:25 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
, 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: 12/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
Type B
Section Cited
HSC
1569.695(c)
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview of the Administrator, the facility has not conducted quarterly emergency drills, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/17/2025
Plan of Correction
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Administrator to submit proof that trainings have been completed to the Department by the Plan of Correction 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.
SUPERVISOR'S NAME:Andrea Medlin
LICENSING EVALUATOR NAME:John Calandra
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2024


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 12/27/2024 04:07 PM - It Cannot Be Edited


Created By: John Calandra On 12/27/2024 at 03:25 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
, 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: 12/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(e)(2)
Other Provisions
(e) A facility shall have all of the following information readily available to facility staff during an emergency: (2) An appraisal of resident needs and services plan for each resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, R1 did not have an Appraisal of resident needs and services plan, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/10/2025
Plan of Correction
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Administrator to submit an updated appraisal of resident needs and services plan for R1 by the POC due date.
Section Cited
Deficient Practice Statement
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2
3
4
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:Andrea Medlin
LICENSING EVALUATOR NAME:John Calandra
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2024


LIC809 (FAS) - (06/04)
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