079200577-9-15-2022-15-AS-LHAL-CJB49R-20220915185447

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200577
Report Date: 09/15/2022
Date Signed: 09/15/2022 06:55:01 PM

Document Has Been Signed on 09/15/2022 06:55 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	SANTA TERESA CARE HOME		FACILITY NUMBER:	079200577
ADMINISTRATOR:	CALAMBRO, MARIVEL N		FACILITY TYPE:	740
ADDRESS:	10 SANTA TERESA CT		TELEPHONE:	(925) 261-9397
CITY:	PITTSBURG	STATE: CA	ZIP CODE:	94565
CAPACITY:	6	CENSUS: 5	DATE:	09/15/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	04:40 PM
MET WITH:	Elaine Gelacio, Caregiver		TIME COMPLETED:	07:05 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	On 9/15/2022 at 4:40PM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA met with Elaine Gelacio, Caregiver and explained the purpose of the visit. LPA spoke with Administrator, Marivel Calambro via telephone. Administrator gave approval for caregiver to sign documents. Upon entry, LPA's temperature was not checked. LPA observed screening station and COVID-19 signs posted near screening station. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, kitchen, garage and back yard. All hand washing stations were equipped with soap and paper towel. Hand washing posters were posted at hand washing stations. Hot water temperature in the shared clients’ bathroom was measured at 131.0 degrees Fahrenheit. Fire extinguisher last serviced on 6/6/2021. During record review, LPA observed facility has a copy of the infection control plan on file. LPA observed paper supplies are sufficient. The following deficiencies were observed: At 4:45PM, LPA observed a pair of scissors and knives in unlocked kitchen cabinet located underneath kitchen sink. Continued on LIC809C.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SANTA TERESA CARE HOME	FACILITY NUMBER: 079200577
	VISIT DATE: 09/15/2022

NARRATIVE

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Continued from LIC809.

At 4:50PM, LPA observed both staff S1 and S2 were not associated to the facility.
At 5:05PM, LPA observed R2 in hospital bed. Facility did not have any doctor's order for hospital bed.

LPA request the following documents to be submitted to CCLD by 9/22/2022.

LIC500 Personnel Report
LIC610E Emergency Disaster Plan
Administrator certificate
LIC308 Designation of facility Responsibility

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in Civil Penalties.

Exit interview conducted. A copy of this report provided and appeal rights provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/15/2022 06:55 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SANTA TERESA CARE HOME	FACILITY NUMBER: 079200577
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(1)

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having the kitchen cabinet unlocked with knives and scissors accessible which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/16/2022
	Plan of Correction
1 2 3 4	Caregiver locked kitchen cabinet immediately making knives and scissors inaccessible. Deficiency cleared during visit.

Type A

Section Cited

CCR

87355(e)(1)

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in having S1 and S2 associated to the facility which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/16/2022
	Plan of Correction
1 2 3 4	Via telephone Administrator agreed to submit LIC9182 and identification for S1 and S2 by POC date to CCLD. S1 and S2's LIC9182 and identification was submitted to LPA during visit. Deficiency cleared during visit

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: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 09/15/2022 06:55 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SANTA TERESA CARE HOME	FACILITY NUMBER: 079200577
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87608(a)(3)

87608 Postural Supports a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review) the licensee did not comply with the section cited above in having a doctor's order for R2 hospital bed which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/22/2022
	Plan of Correction
1 2 3 4	Via telephone Administrator agreed to submit a copy of a doctor's order for the hospital bed to CCLD by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

LIC809 (FAS) - (06/04)

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