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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202787
Report Date: 12/03/2021
Date Signed: 12/22/2021 08:50:54 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:ST. THERESE ELDERLY CARE FACILITYFACILITY NUMBER:
435202787
ADMINISTRATOR:BENITEZ, MICHELLEFACILITY TYPE:
740
ADDRESS:5903 CAHALAN AVETELEPHONE:
(408) 578-8068
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY:6CENSUS: 2DATE:
12/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:04 AM
MET WITH:Michelle BenitezTIME COMPLETED:
02:27 PM
NARRATIVE
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 12/03/2021 at 11:04am. LPA met with facility Administrator Michelle Benitez (Admin).

LPA toured the facility, including living room, kitchen, dining room, 5 client bedrooms, 1 staff bedroom, 2 bathrooms, back yard, and garage. All staff members observed to be wearing masks. Admin confirmed that all staff and residents have been vaccinated.

Facility observed to have designated entry point. Staff took LPA's temperature but did not screen for symptoms. 30 day supply of PPE observed. Restrooms were not stoked with paper towels. Hand washing signs were not observed to be in all bathrooms. Social distancing signs observed to be posted in all public areas. The facility is currently accepting visitors inside the facility, including residents' bedrooms.

Facility Mitigation plan has already been submitted. No prohibited items noted in resident rooms. All emergency exits noted to be clear of obstruction. All rooms in facility noted to be clean and well maintained. Hand sanitizers, soap, and paper supplies were observed to be available. At least 2 days' supply of perishable food and at least 1 week's supply of non-perishable food was observed on the premises. Fire extinguishers observed to be inspected in 2021. Facility carbon monoxide detector tested and observed to be in working order. Facility water temperature observed to be at 141.1 *F in both facility bathrooms, which is 21.1 degrees over the maximum temperature stipulated in Title 22.

Deficiency was cited during today's visit. See 809-D. This report was reviewed with Administrator Michelle Benitez and a copy of the signed report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021
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, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: ST. THERESE ELDERLY CARE FACILITY
FACILITY NUMBER: 435202787
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)

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, the licensee did not comply with the section cited above in 2 out of 2 bathrooms in which the water temperature was measured to be 141.1 *F, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/04/2021
Plan of Correction
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Corrected during inspection by turning down the temperature on the water heater
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: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2021
LIC809 (FAS) - (06/04)
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