435294297-8-11-2025-26-AS-CKAI-DKFR2S-20250811123848

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435294297
Report Date: 08/11/2025
Date Signed: 08/11/2025 12:38:59 PM

Document Has Been Signed on 08/11/2025 12:38 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/ DIRECTOR:	ZIPAGAN, SANDY		FACILITY TYPE:	740
ADDRESS:	985 FITZGERALD AVENUE		TELEPHONE:	(408) 461-2089
CITY:	SAN MARTIN	STATE: CA	ZIP CODE:	95046
CAPACITY: 6		CENSUS: 6	DATE:	08/11/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:00 AM
MET WITH:	Triponia "Pony" Tuazon		TIME VISIT/ INSPECTION COMPLETED:	12:45 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 Kabariti arrived unannounced to conduct the facility's required - 1 year annual inspection. LPA met with Assistant Administrator (AA), Triponia "Pony" Tuazon and Designated Administrator Jermaine Aguirre. During visit, LPA toured the facility with the AA and staff to include the dining room, living room, kitchen, medication room, garage, 4 resident bedrooms, 2 staff rooms, 4 bathrooms, backyard, and exterior. All fire exit routes and ramps are free and clear of obstruction. All staff are fingerprint cleared and associated to the facility. In the backyard, LPA observed a seating area that was not shaded. Staff stated they used to have an umbrella connected to the table, however the umbrella broke. Staff immediately purchased an outdoor umbrella and showed LPA proof of purchase during visit. Facility temperature maintained at 73 degrees F. Facility has at least 2 days worth of perishables and 7 days worth of non-perishable foods. All items inside the refrigerator/freezer are covered and labeled. Refrigerator temperature maintained at 36 degrees F. Freezer temperature maintained at -2 degrees F. Carbon monoxide detector present and observed operable. Fire extinguisher last serviced of 06/03/2025. Medications and sharp objects observed locked in the pantry with the non-perishable foods. Snacks and fruits observed accessible in the kitchen for the residents. Chemicals, disinfectants, and toxins observed locked and stored separately from the food supply. First aid kit observed. See LIC809-C.

NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/11/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2025

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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: ST. THERESE HOMES, INC.	FACILITY NUMBER: 435294297
	VISIT DATE: 08/11/2025

NARRATIVE

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Resident bedrooms equipped with proper furniture to include beds, linens, dressers, night stands, and adequate lighting. LPA observed 2 resident beds equipped with half rails in which the 2 resident's has a physician's order for use.

Bathroom hot water temperature in bedroom #2 observed at 95.5 - 96.9 degrees F. The bathroom hot water temperature in the hallway observed at 109.9 degrees F. LPA observed a water temperature log which staff are monitoring the hot water temperature daily in the kitchen, hallway, and master bedroom. Staff measured the hot water temperature this morning which measured at 110 degrees F. LPA advised to ensure the hot water temperature in bedroom #2 is maintained within Title 22 regulations. Advisory note provided for bedroom #2's hot water temperature.

LPA reviewed 3 resident files were complete and up-to-date. 3 residents centrally stored medications and centrally stored medication records were reviewed and all medications were accounted for. 3 resident's P&I money was reviewed.

LPA reviewed 4 staff files were complete to include an active first aid certification, fingerprint clearance, health screening and TB result. Staff are provided annual training on topics relating to dementia care, postural supports, hospice care, restricted health conditions, incident reporting, abuse, personal rights, and medications.

Facility has an updated emergency disaster plan. Emergency drills are completed quarterly and the last drill was completed on 08/01/2025. Emergency supplies observed to include flashlights, batteries, and portable power station. Facility has an infection control plan. PPE items to include gloves, hand sanitizer, face masks observed next to the isolation room.

The following documents were obtained to update the facility file: Administrator certificates, LIC308, LIC400, surety bond, LIC610E, and LIC500.

No deficiencies were cited per California Code of Regulations, Title 22. Advisory note provided. This report was reviewed with Assistant Administrator (AA), Triponia "Pony" Tuazon and Designated Administrator Jermaine Aguirreand a copy of the report was provided.

NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/11/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2025

LIC809 (FAS) - (06/04)

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