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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200335
Report Date: 01/27/2024
Date Signed: 01/27/2024 04:37:28 PM

Document Has Been Signed on 01/27/2024 04:37 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:TERESA RESIDENTIAL CARE HOMEFACILITY NUMBER:
435200335
ADMINISTRATOR:ALLAN G. CEASEFACILITY TYPE:
735
ADDRESS:3298 ARQUEADO DRIVETELEPHONE:
(408) 532-1376
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY: 6CENSUS: 4DATE:
01/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Administrator Allan G. CeaseTIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with staff member, Severino Sanchez, S1. Administrator Allan Cease arrived later during inspection. During visit, LPA observed 2 residents and 1 staff.

LPA toured the facility inside out with S1 which included; the Living room, kitchen, dining room, 2 restrooms. While touring the facility hallway restroom, LPA observed two spray bottles with cleaning solutions, Mold and Mildew stain remover & Shout. (Photographs taken.) LPA toured the 3 resident bedrooms. LPA observed bedroom #2 does not have its sliding door screen.( Photograph taken.) LPA observed bedroom 3's window screen also has stains and residue. (Photographs taken.) The staff area of the facility was also inspected. Front yard and backyard were inspected. LPA observed a shed directly across from bedroom #4. LPA asked S1 to open the door. S1 stated he/she sometimes rests in the shed. LPA observed a mattress, pillow, blankets, cloths and medication. (Photographs taken) ADM stated he also sleeps in the shed as well. While touring the backyard, LPA observed a propane tank in a tank of green water. ADM stated the shed was added about 2 years ago during covid. There was no obstruction to block the walkways.

Two day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, and cleaning product storage area as locked and inaccessible to residents in care. ADM showed LPA the knives storeage area. Knives are being stored outside the kitchen, inside the lower portion of the black stove. The lower portion of the black stove does not have a locking mechanism, leaving the knives accessible to residents in care. (photographs taken.) Room temperature was at 70 degrees F, and hot water temperature was measured at 116 degrees F in resident bathroom.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2024
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 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: TERESA RESIDENTIAL CARE HOME
FACILITY NUMBER: 435200335
VISIT DATE: 01/27/2024
NARRATIVE
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Dinning room and garage Fire extinguisher was serviced in December, 2022. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by S1, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on June 15, 2023.

LPA reviewed facility records for 3 residents. R1-R3's needs and services plans did not address any of the residents needs when cross referencing their physicians report. (photographs taken). LPA requested to review 3 staff files. ADM stated he can not find the files. LPA requested to review 3 resident medications and centrally stored medication records. ADM stated he does not have acess to the centrally stored records and they are in the computer. LPA reviewed 3 resident P&I records. LPA conducted interviews with 2 staff (S1 and ADM) and 2 residents (R1-R2). The other residents were visiting their family during LPA's visit.

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. Exit interview was conducted with Administrator Allan G. Cease and a copy of the signed report & appeal rights were provided.

Page 2 out of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2024
LIC809 (FAS) - (06/04)
Page: 7 of 7
Document Has Been Signed on 01/27/2024 04:37 PM - It Cannot Be Edited


Created By: Manuel Monter On 01/27/2024 at 03:47 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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: TERESA RESIDENTIAL CARE HOME
FACILITY NUMBER: 435200335

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

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. LPA observed a propane tank in a tank of green water directly outside Bedroom #2's sliding door. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/03/2024
Plan of Correction
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ADM stated he will send a plan of action on how he will ensure the facility is clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. ADM stated he will send plan of action by poc date, 02/03/2024.
Type B
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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. LPA observed 2 spray bottles with cleaning solutions, Mold & Mildew stain remover & Shout in facility hallway restroom. LPA also observed facility knives storage location acessible to residents. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/03/2024
Plan of Correction
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ADM stated he will send plan of action on how the facility will ensure, cleaning solutions and other items such as knives are inacessible to residents in care. ADM stated he will send plan of action to LPA by POC date 02/03/2024.
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:Romeo Manzano
LICENSING EVALUATOR NAME:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2024


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 01/27/2024 04:37 PM - It Cannot Be Edited


Created By: Manuel Monter On 01/27/2024 at 03:47 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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: TERESA RESIDENTIAL CARE HOME
FACILITY NUMBER: 435200335

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

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. LPA observed bedroom #3's window and the kitchen window screen with dirt and other debris. LPA also observed bedroom #2 did not have its sliding door screen. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/03/2024
Plan of Correction
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ADM stated he will send plan of action on how the facility will ensure window screens will be in good repair and be free of dirt and other debris.
Type B
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above. LPA observed shed in the backyard had clothing, a bed, with blankets. ADM stated he does sleep in the shed. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/03/2024
Plan of Correction
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ADM will send photo documentation showing the storage area is no longer being used as a sleeping area. ADM stated he will also send a letter of understanding stating no staff or any individual is allowed to sleep in the following areas without building permit and fire clearance such as but not limited storage room, living room, and garage.
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:Romeo Manzano
LICENSING EVALUATOR NAME:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2024


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 01/27/2024 04:37 PM - It Cannot Be Edited


Created By: Manuel Monter On 01/27/2024 at 03:47 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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: TERESA RESIDENTIAL CARE HOME
FACILITY NUMBER: 435200335

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(e)
Personnel Records
(e) All personnel records shall be maintained at the facility site.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above. LPA requested to review 3 staff records. ADM stated he cannot find the records. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/03/2024
Plan of Correction
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ADM stated he will send plan of action on how the facility will ensure facility staff files are in the facility for inspection. ADM stated he will send plan of action by POC date, 02/03/2024.
Type B
Section Cited
CCR
85068.3(a)
Modifications to Needs and Services Plan
(a) The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently as necessary to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental and/or social functioning.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Based on records reviewed, R1-R3's needs and services plans do not address any of the residents needs when cross referencing their physicians report. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/03/2024
Plan of Correction
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ADM stated he will send LPA updated needs and services plans to LPA by POC date, 02/03/2024.
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:Romeo Manzano
LICENSING EVALUATOR NAME:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2024


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 01/27/2024 04:37 PM - It Cannot Be Edited


Created By: Manuel Monter On 01/27/2024 at 03:47 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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: TERESA RESIDENTIAL CARE HOME
FACILITY NUMBER: 435200335

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(d)
Client Records
(d) All client records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above LPA requested to see residents centrally stored medication records. ADM stated he does not have it. The records were not provided to LPA to review. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/03/2024
Plan of Correction
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ADM stated he will send plan of action on how the facility will have residents records avaialbe to the licensing agency to inspect and audit. ADM stated he will send plan of action by 02/03/2024
Type B
Section Cited
HSC
1565(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 individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, 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, the licensee did not comply with the section cited above. Based on record review The facility's last drill was on June 15, 2023. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/03/2024
Plan of Correction
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ADM stated he will conduct a drill and send LPA documentaion a drill has taken place by poc date, 02/03/2024.
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:Romeo Manzano
LICENSING EVALUATOR NAME:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2024


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 01/27/2024 04:37 PM - It Cannot Be Edited


Created By: Manuel Monter On 01/27/2024 at 03:47 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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: TERESA RESIDENTIAL CARE HOME
FACILITY NUMBER: 435200335

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80023(b)(2)
Disaster & Mass Casualty Plan
(b) The plan shall be subject to review by the licensing agency and shall include: (2) Contingency plans for action during fires, floods, and earthquakes, including but not limited to the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above. Based on LPA's observation, the garage and dinning room fire extinguishers were last inspected on December 2022. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/03/2024
Plan of Correction
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2
3
4
ADM stated he will either replace or obtain inspection of current fire extinguishers, by POC date. ADM statedhe will send LPA written plan to ensure the facility fire extinguisher is serviced at least annual. ADM stated he will send the plan by poc date, 02/03/2024.
Section Cited
Deficient Practice Statement
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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:Romeo Manzano
LICENSING EVALUATOR NAME:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2024


LIC809 (FAS) - (06/04)
Page: 6 of 7