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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294297
Report Date: 08/09/2024
Date Signed: 08/09/2024 11:33:49 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/09/2024 11:33 AM - 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: 6DATE:
08/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Triponia Tuazon Asst AdministratorTIME COMPLETED:
11:30 AM
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On 8/9/2024 at 9:00 a.m. Licensing Program Analysts (LPAs) Maria Partoza, Marcella Tarin and Marcela Yanez arrived unannounced to conduct an annual required inspection. LPAs were greeted by two staff, and met with Triponia Tuazon, Assistant Administrator. LPAs stated the purpose of the visit.

This facility is a Residential Care Facility for the Elderly (RCFE) serving adult 60 and over. 4 may be non-ambulatory, two may be bedridden in bedroom #1 and 2 hospice waiver. LPAs observed 3 of 6 residents in the activity, 3 of 6 were in their bedroom. 5 of 6 are non-ambulatory. 6 of 6 residents are developmentally disabled.

At 9:10 a.m. LPAs with Staff 1, toured the facility inside and outside including the bedrooms, bathrooms, kitchen, and living room. Bedrooms and bathrooms were observed organized and sanitary. Bedrooms have sufficient storage for residents personal belongings. Bathrooms are equipped grab bars and nonskid floor mats. Facility hallways have night lights that are in good working condition. LPAs observed fire extinguishers inspected on 6/5/2024. Hot water temperature is maintained at 115-118 degrees F. The facility had their inspection by the fire Marshall on 7/31/2024. Facility temperature is maintained at 72 degrees Fahrenheit.
The facility is equipped with carbon monoxide and smoke alarm system that are in good working condition.

LPAs observed the kitchen to be organized and sanitary, no knives and no sharps are accessible to residents. LPAs observe a locked cabinet for the toxic and are not accessible to residents. LPAs observed the medication cabinet to be locked and secured and not accessible to residents. LPA observed 2 days of perishables and 7 days of nonperishable for the number of clients and staff.

LPAs reviewed 4 of 6 resident record, including Centrally stored medications 3 of 3 staff record and observed records to be updated and complete. ~~~~~ page 1 of 2 see LIC 809C
SUPERVISOR'S NAME: Jin JackieTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marcella TarinTELEPHONE: (714) 328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2024
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 2


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: 08/09/2024
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LPAs discussed an provided technical advisory to assistant administrator pertaining to 1 of 4 resident record update.

LPAs reviewed 4 of 6 residents records and 3 of 3 staff records and facility record. LPAs observed residents, staff and facility record to be updated and complete. Fire & Earthquake drill training is updated and done every quarter. LPAs observe the first aid kit is complete and can be easily accessed by staff.

No deficiencies were cited during today's visit based on California Code of Regulations (CCR) Title 22. An exit interview was conducted with Assistant Administrator Triponia Tuazon. A copy of the report was provided.

End of Report
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SUPERVISOR'S NAME: Jin JackieTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marcella TarinTELEPHONE: (714) 328-5152
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024
LIC809 (FAS) - (06/04)
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