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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600700
Report Date: 07/27/2019
Date Signed: 07/27/2019 02:42:50 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME:THERESE RESIDENTIAL CARE HOMEFACILITY NUMBER:
415600700
ADMINISTRATOR:DELA RUEDA, MAY L.FACILITY TYPE:
740
ADDRESS:1787 REX STREETTELEPHONE:
(650) 572-8389
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY:6CENSUS: 6DATE:
07/27/2019
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:May dela RuedaTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct an annual required inspection and was met by staff Arnie dela Rueda. Administrator arrived at around 12:30 pm.

LPA inspected the facility inside and out including but not limited to 6 resident rooms, 2 bathrooms, kitchen, dining and outside areas. There were sufficient lights and lamps observed for each room. Facility was observed clean and odor free. Facility temperature was comfortable at 72 degrees Fahrenheit. Hot water measured at 109.9 degrees Fahrenheit. Bath/shower rooms were observed with grab bars, shower chairs and non skid flooring. Hygiene products , linen, towels and blankets in ample amount were also observed. Medications were locked in a cabinet in the kitchen. Fire extinguisher that appeared full and was last serviced on 5/24/19 was observed on the wall in the kitchen. There is a carbon monoxide in the living room that is functional. First aid kit was observed complete. Last disaster drill was conducted In January 2019.

While conducting physical plant inspection at 12:15 pm, LPA observed knives and other sharps in a drawer in the kitchen unlocked.

At 1:05 pm, LPA reviewed 6 resident files and 4 staff files. 3 out of 4 staff have 1st aid and CPR that expired on 7/11/19.

At 2pm, LPA reviewed medication and log.

Deficiencies were cited per Title 22 California Code of Regulations. Refer to Lic 809 D.

Exit interview conducted; Appeal Rights provided.


SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2019
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: THERESE RESIDENTIAL CARE HOME
FACILITY NUMBER: 415600700
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/27/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/27/2019
Section Cited
CCR
87705(f)(2)
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Care of Persons with Dementia
Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Based on observation, facility failed to lock
knives and other sharp objects in a drawer
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Administrator provided a lock to the drawer while LPA was at the facility; deficiency cleared.
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in the kitchen which poses an immediate risk to health and safety of clients under care.
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Type B
08/02/2019
Section Cited
CCR
87411(c)(1)
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Personnel Requirements - General
Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:


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By POC date, Administrator will submit to CCL proof of current 1st aid and CPR of S2, S3 and S4
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LPA observed that 3 out of 4 staff(S2, S3 and S4) have 1st aid and CPR that expired on 7/11/19 which poses a potential risk to health and safety of clients under care.
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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.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2019
LIC809 (FAS) - (06/04)
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