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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600700
Report Date: 05/19/2025
Date Signed: 05/19/2025 04:48:49 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 05/19/2025 04:48 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:THERESE RESIDENTIAL CARE HOMEFACILITY NUMBER:
415600700
ADMINISTRATOR/
DIRECTOR:		DELA RUEDA, MAY L.FACILITY TYPE:
740
ADDRESS:1787 REX STREETTELEPHONE:
(650) 572-8389
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY: 6CENSUS: 5DATE:
05/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Caregiver - Emelita CapistranoTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On 05/19/2025, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced required 1 year inspection. LPA met with caregiver Emielita Capistrano and explained the purpose of today's visit. Currently there are 5 residents present and 2 caregivers during today's inspection visit.

The facility is licensed for age range 60 years and over. All are approved to be non-ambulatory. Hospice waiver for 5 residents. Currently there are 2 residents on hospice per staff interviewed. Rooms 3 and 4 are approved to be for bedridden residents. The facility ambient temperature is comfortable. The required postings are in place observed in main dining area adjacent to the kitchen. Water temperature is tested in the common hallway full bathroom measuring as 120F. The facility has two full bathrooms and both were tested at 120F. Both are equipped with grab bars and non-skid mats. Cleaning supplies are observed to be locked in the garage primarily and a few cleaning supplies are locked below the kitchen sink. Facility knives are observed to be locked in a kitchen cabinet adjacent to the refrigerator. Facility food supplies are observed to be in place with 2 day fresh food supply and canned goods fulfilling the 7 day emergency food supply. Laundry area is observed in the garage as well and is fully operational. Additional cleaning supplies are observed to be locked in a large storage closet in the garage. A tour of the outside of the facility is conducted. Emergency routes are free and clear of any obstructions. There is a locked storage shed in the backyard that contains garden supplies and furniture. Smoke detectors and carbon monoxide detectors are located through out the facility. LPA observed 2 fire extinguishers are observed in the facility. Both with inspection dates of 05/15/2025. Both are charged and ready for use. Facility conducts emergency drill quarterly. The last drill that was conducted is logged 05/01/2024. Linens are in place for resident in care as observed in a hallway closet near Room 1.

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NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Jaime Vado
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2025
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: THERESE RESIDENTIAL CARE HOME
FACILITY NUMBER: 415600700
VISIT DATE: 05/19/2025
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LPA observed all resident rooms and observed that they contain the required furniture and lighting as outlined in Title 22. Medications are current, locked, and logged appropriately. First aid kit is present. Hygiene supplies are in place. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed as current. LPA reviewed 4 resident files and 3 staff files on this day. All files reviewed are current. Administrator certificate for licensee/administrator May E. Dela Rueda is observed as expired on 11/16/2024 and Emelita Capistrano is current expiring 09/06/2025.

The following updated items are to be received by 05/26/2025:
• Copy of administrator certificates
• Copy of facility's liability insurance
• LIC308 Designation of responsible staff person
• LIC402 Surety bond and Copy of active bond
• LIC610E Emergency Disaster Plan
• LIC500 Staff Schedule


Report is reviewed with Emelita Capistrano. A copy of this report is provided to the facility. No deficiencies cited as a result of today's inspection visit.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Jaime Vado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
LIC809 (FAS) - (06/04)
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