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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600700
Report Date: 04/26/2024
Date Signed: 04/26/2024 02:54:24 PM


Document Has Been Signed on 04/26/2024 02:54 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



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: 5DATE:
04/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Millet Capistrano and Arnie Dela RuedaTIME COMPLETED:
03:00 PM
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LPA Audrey Jeung toured facility and grounds, including two detached storage units and attached garage. There are 6 private client bedrooms, 3 full bathrooms, kitchen, living/dining area; two rear bedrooms with exits are cleared for bedridden clients. No accessible bodies of water or fire safety hazards observed. Medications, toxins and sharps are stored appropriately and inaccessible to clients, and a comfortable room temperature is maintained. Hot water temperature is tested at 120 degrees in shared client bathroom. Food supply and first-aid kit are inspected, and carbon monoxide detector is tested and operable. All client files are reviewed, and medications are recorded on Centrally Stored Medications Records. An updated Disaster and Mass Casualty Plan is posted. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, as well as staff records. May Dela Rueda (x 11/24) and Emelita Capistrano are certified RCFE administrators that oversee facility operations.

The following forms are left with facility representative to be completed and returned to CCL by 5/10/24:

• LIC 309 Administrative Organization
• LIC 308 Designation of Administrative Responsibility
• LIC 500 Personnel Report
• LIC 610D Emergency Disaster Plan (9pages)
• Proof of current liability insurance
• Proof of control of property (current signed lease agreement)


Deficiencies of the California Code of Regulations, Title 22 are observed and cited on a following page:
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2024
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 3


Document Has Been Signed on 04/26/2024 02:54 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: THERESE RESIDENTIAL CARE HOME
FACILITY NUMBER: 415600700

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, as two half bed rails are installed on bed of client #3, because he has behavior of getting out of bed on his own and wandering.
This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/29/2024
Plan of Correction
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Lower half bed rail is removed from bed of client #3. Administrator to submit acknowledgement that client cannot be restrained by use of full bed rails BY 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.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 04/26/2024 02:54 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: THERESE RESIDENTIAL CARE HOME
FACILITY NUMBER: 415600700

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(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 absence of documentation, the licensee did not comply with the section cited above, as there is no documentation that Emergency disaster drills were conducted.
This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2024
Plan of Correction
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Plan/proof of correction to be sent to CCLD BY 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.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3