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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508550
Report Date: 01/16/2026
Date Signed: 01/16/2026 03:38:39 PM

Document Has Been Signed on 01/16/2026 03:38 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: 5DATE:
01/16/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Teofila Oueis, Administrator TIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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On 1/16/2026, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct the Annual 1-year required inspection. LPA Calandra was greeted by Teofila "Sophie" Oueis, Administrator and explained the purpose of the visit.

LPA toured the physical plant. This is a 1-story building with 7 bedrooms, 9 and a half bathrooms, a kitchen, living room, dining room, office, laundry room, and front yard. No accessible bodies of water or hazards were observed. All bedrooms had the required furniture and sufficient lighting. All bathrooms had anti-skid flooring and grab bars. The facility's smoke alarms and carbon monoxide detectors were observed to be in working order. The facility's fire extinguishers were observed to be fully charged and last checked on 12/11/2025. The facility had the required 7 days of non perishables and 2 days of perishables on hand. No food was expired.

All sharp objects, soap, poisons, detergents, and medications were observed to be locked and in-accessible to persons in care.

LPA reviewed 5 resident files and 3 staff files. All resident files except two that were missing Appraisals of Needs and Services.

During the physical plant tour, LPA observed that hot water temperature was measured at 164 degrees Fahrenheit which is outside of the required 105-120 degree range. A Type A citation was provided for this deficiency.
NAME OF LICENSING PROGRAM MANAGER: Brenda Chan
NAME OF LICENSING PROGRAM ANALYST: John Calandra
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2026
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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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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 CARLOS
FACILITY NUMBER: 410508550
VISIT DATE: 01/16/2026
NARRATIVE
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During record review, LPA observed that facility staff did not have the required 8 hours of Dementia training and 4 hours of training on postural supports, hospice, and restricted health conditions within the last year. In addition, LPA observed that 2 residents did not have appraisals of needs and services. Type B citations were provided for these deficiencies.

Deficiencies are cited under the California Code of Regulations(CCR), Title 22. Failure to correct the Deficiencies by the Proof of Correction(POC) due date may result in Civil Penalties.

The Annual Inspection will be completed at a later date.

An exit interview was conducted. A copy of this report along with Appeal Rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Brenda Chan
NAME OF LICENSING PROGRAM ANALYST: John Calandra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2026
LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 01/16/2026 03:38 PM - It Cannot Be Edited


Created By: John Calandra On 01/16/2026 at 03:09 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: 01/16/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.696(a)(1)
HSC 1569.696(a)(1) 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: (1)Four hours of training on the care, supervision, and special needs of those residents, prior to providing direct care to residents.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the Licensee did not ensure that their staff had been provided training within the last year including four hours on the subjects of postural supports, restricted health conditions, and hospice care which is a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/30/2026
Plan of Correction
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Licensee will conduct training and send list of atendees, subjects of trainings and dates to the Department by the POC due date.
Type B
Section Cited
HSC
1569.695(e)(2)
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 document review, Licensee did not ensure that an appraisal of resident needs and services plan had been created for R1 and R2 which is a potential health, safety, or personal rights risk to persons in care.
POC Due Date: 01/30/2026
Plan of Correction
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Licensee will create an appraisal of resident needs and services plan for R1 and R2 and submit them to the Department 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.
Brenda Chan
NAME OF LICENSING PROGRAM MANAGER:
John Calandra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/16/2026 03:38 PM - It Cannot Be Edited


Created By: John Calandra On 01/16/2026 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: 01/16/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
87303(e)(2): Maintenance and Operations: Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, Licensee did not ensure hot water temperature was maintained between 105-120 degrees as evidenced by temperature reading of 164 degrees during the inspection, which is an immediate health, safety, or personal rights risk to persons in care.

POC Due Date: 01/17/2026
Plan of Correction
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Licensee will turn down water temperature and send proof of correction by the POC due date.
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.
Brenda Chan
NAME OF LICENSING PROGRAM MANAGER:
John Calandra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2026


LIC809 (FAS) - (06/04)
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