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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200577
Report Date: 09/11/2024
Date Signed: 09/11/2024 06:05:20 PM


Document Has Been Signed on 09/11/2024 06:05 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 HOMEFACILITY NUMBER:
079200577
ADMINISTRATOR:CALAMBRO, MARIVEL NFACILITY TYPE:
740
ADDRESS:10 SANTA TERESA CTTELEPHONE:
(925) 261-9397
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY:6CENSUS: 4DATE:
09/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Elaine Francisco, CaregiverTIME COMPLETED:
06:15 PM
NARRATIVE
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On 09/21/2023 at 2:30PM, Licensing Program Analyst (LPA) L. Hall conducted an unannounced annual required inspection. LPA met with caregiver, Elaine Francisco, and explained the purpose of the visit. The administrator, Marivel Calambro arrived at 2:00pm. The facility’s fire clearance was approved for five (5) non-ambulatory and one (1) bedridden residents.

LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of six (6) bedrooms. One (1) bedroom occupied by staff. All outdoor and indoor passageways are kept free of obstruction. A comfortable temperature is maintained at 73 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 102.2 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 08/29/2024. Emergency Disaster Plan was last posted on 08/14/2024. First aid kit was observed to be complete. Fire drill was last conducted on 07/20/2024.

Continued on LIC809.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2024
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: 09/11/2024
NARRATIVE
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Continued from LIC809.

Four staff records were reviewed. LPA also reviewed all four (4) resident records which were incomplete.

LPA observed the following deficiencies:
  • At 1:45pm, LPA observed during record review LPA observed all four (4) resident files were incomplete.
  • At 1:45pm, LPA observed during record review facility did not submit a hospice initiation notification for R1.
  • At 1:45pm, LPA observed during record review that facility did not report R1's hospitalization.
  • At 1:45pm, LPA observed R3 had a half-rail but facility does not have a doctor's order.
  • At 2:15pm, LPA observed during record review S2 does not have a health screening.
  • At 2:45pm, LPA observed facility have two (2) bedridden residents located in bedrooms 2 and 3.
  • At 4:30pm, LPA observed during record review facility did not maintain a record of each dose in the resident's record.

LPA requested the following documents to be submitted to CCLD by 9/18/2024.
  • LIC 308 Designation of Administrative Responsibility
  • LIC 500 Personnel Report
  • LIC 610E Emergency Disaster Plan (last page)
  • Liability Insurance

Continued on LIC809C.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024
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: 09/11/2024
NARRATIVE
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Continued from LIC809C.

*An immediate civil penalty of $750.00 will be assessed on today's day*

87202(a)(2) = $500.00 1x
87608(a)(3) = $250.00 for repeat

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy appeal rights and this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/11/2024 06:05 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: 09/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)(2)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in having two bedridden residents and non-ambulatory in a room that is assigned for ambulatory only which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/12/2024
Plan of Correction
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2
3
4
Administrator agreed to submit and updated facility sketch and LIC200 for a new fire clearance to CCLD by POC date.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 09/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2024
LIC809 (FAS) - (06/04)
Page: 4 of 8


Document Has Been Signed on 09/11/2024 06:05 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: 09/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87211(a)(1)
Reporting Requirements
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in reporting a hospitalization incident to CCLD which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/18/2024
Plan of Correction
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Administrator agreed to submit an incident report for R1's hospitalization to CCLD by POC date.
Type B
Section Cited
CCR
87506(a)
87506 Resident Records

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in having resident records current and complete which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/18/2024
Plan of Correction
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Administrator agreed to complete resident records and submit a self-certification that the records have been submitted to CCLD by POC date.
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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 09/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2024
LIC809 (FAS) - (06/04)
Page: 5 of 8


Document Has Been Signed on 09/11/2024 06:05 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: 09/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
87412 Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

(11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in having S2 a health screening which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/18/2024
Plan of Correction
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Administrator agreed to obtain a health screening for S2 and submit a copy to CCLD by POC date.
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
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in having a doctor's order for a half bed rail for R3 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/18/2024
Plan of Correction
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Administrator agreed to obtain a doctor's order for the half bed rail for R3 and submit a copy to CCLD by POC date.
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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 09/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2024
LIC809 (FAS) - (06/04)
Page: 7 of 8


Document Has Been Signed on 09/11/2024 06:05 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: 09/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465
87465 Incidental Medical and Dental Care
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:
(3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in having a record of each does maintained at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/18/2024
Plan of Correction
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Administrator agreed to obtain records for each resident that takes medication submit a copy of the record to CCLD by POC date.
Type B
Section Cited
CCR
87632(d)(2)
87632 Hospice Care Waiver
(d) If the Department grants a hospice care waiver it shall stipulate terms and conditions of the waiver as necessary to ensure the well-being of terminally ill residents and of all other facility residents, which shall include, but not be limited to, the following requirements:
(2) The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services. The notice shall include the resident's name and date of admission to the facility and the name and address of the hospice.

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 submitting a hospice initiation for R1 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/18/2024
Plan of Correction
1
2
3
4
Administrator agreed to submit hospice initiation for R1 to CCLD by POC date.
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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 09/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2024
LIC809 (FAS) - (06/04)
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