<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294297
Report Date: 08/23/2022
Date Signed: 08/23/2022 02:22:05 PM


Document Has Been Signed on 08/23/2022 02:22 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:ST. THERESE HOMES, INC.FACILITY NUMBER:
435294297
ADMINISTRATOR:ZIPAGAN, SANDYFACILITY TYPE:
740
ADDRESS:985 FITZGERALD AVENUETELEPHONE:
(408) 461-2089
CITY:SAN MARTINSTATE: CAZIP CODE:
95046
CAPACITY:6CENSUS: 5DATE:
08/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Sandy ZipaganTIME COMPLETED:
02:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual inspection focusing on infection control. LPA met with Administrator, Sandy Zipagan.

During visit, LPA toured the facility to include the dining rooms, living room, kitchen, medication room, bedrooms, bathrooms, garage, and backyard. All fire exit routes are free and clear of obstruction. All staff observed to be wearing a face covering. Medications and sharp objects observed secured. LPA observed 2 days worth of perishables and 7 days worth of non-perishable foods. Facility temperature maintained at 73 degrees Fahrenheit. Hot water temperature maintained at 106.1 degrees Fahrenheit.

Facility has a designated symptom screening and temperature check for all visitors and staff. Hand sanitizer made available at entry and throughout the facility. Bathrooms supplied with hygiene products, paper supplies, and hand washing sign. Facility staff clean and disinfect multiple times daily and as needed. LPA observed facility's Personal Protective Equipment (PPE) supplies. Isolation room supplied with PPE cart, donning and doffing sign, and trash bin with lid. Licensee is working on providing N95 fit-testing for staff. LPA reviewed the facility's procedures to training, testing, isolation, and monitoring. Signs observed to include social distancing, symptoms of COVID, and visitation guidelines.

The following documents obtained during visit to include the LIC308 and Administrator Certificate.

No deficiencies were cited per California Code of Regulations, Title 22. Advisory note provided.

This report was reviewed with Administrator, Sandy Zipagan and a copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2022
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 2