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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601478
Report Date: 10/16/2025
Date Signed: 10/16/2025 01:42:06 PM

Document Has Been Signed on 10/16/2025 01:42 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:ST JOSEPH SENIOR CAREFACILITY NUMBER:
015601478
ADMINISTRATOR/
DIRECTOR:		CLARISSA R VILLEDOFACILITY TYPE:
740
ADDRESS:6437 DAPHNE CTTELEPHONE:
(510) 795-7603
CITY:NEWARKSTATE: CAZIP CODE:
94560
CAPACITY: 6CENSUS: 3DATE:
10/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Zenaida BautistaTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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On this day at around 10:00 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct an annual required inspection. LPA met with Administrator Zenaida Bautista and explained the purpose of the visit.

During the visit, LPA inspected the facility inside and out including but not limited to 3 resident rooms, bathroom, kitchen, dining, garage and backyard. Hot water in the kitchen measured at 127.6 degrees Fahrenheit. Smoke detector and carbon monoxide were tested and observed functional. Fire extinguisher was observed full and was purchased on 2/8/2025. There was sufficient supply of both perishable and non perishable foods. LPA observed ample supply of towels, sheets, linen and hygiene products.

LPA reviewed 2 resident and 2 staff files. LPA interviewed one resident. First aid kit was observed complete. Facility has liability insurance. Last fire drill was conducted on 6/15/2025.

Deficiencies were cited per Title 22 California Code of Regulations (see attached Lic 809D). 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.

The following records were requested to be submitted to CCL by 10/23/2025: Lic 500, Roster of Residents, updated Emergency Disaster Plan, Liability Insurance.
Exit interview was conducted and Appeal Rights was provided to Bautista.
NAME OF LICENSING PROGRAM MANAGER: Yvonne Flores-Larios
NAME OF LICENSING PROGRAM ANALYST: Luisa Fontanilla
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2025
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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Document Has Been Signed on 10/16/2025 01:42 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 10/16/2025 at 12:23 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ST JOSEPH SENIOR CARE
FACILITY NUMBER: 015601478

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having hot water measuring at 127.6F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/17/2025
Plan of Correction
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The Administrator will adjust hot water between 105-120F and submit self-certification of correction by POC date.
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in leaving Lysol and other cleaning chemicals unlocked in the bathroom which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/17/2025
Plan of Correction
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The Administrator will lock all chemicals and submit self certification of correction 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.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Luisa Fontanilla
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 10/16/2025 01:42 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 10/16/2025 at 12:23 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ST JOSEPH SENIOR CARE
FACILITY NUMBER: 015601478

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(c)
Care of Persons with Dementia
(c) With the prior written approval of the resident or conservator and provided such devices do not violate the resident’s rights as specified in Section 87468.1 Personal Rights of Residents in All Facilities, the licensee may use egress alert and location tracking devices as needed to ensure resident safety.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in installing a child gate on R1's room which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/17/2025
Plan of Correction
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The Administrator states child gate will be removed and will submit photo proof to CCL by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Luisa Fontanilla
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 10/16/2025 01:42 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 10/16/2025 at 12:23 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ST JOSEPH SENIOR CARE
FACILITY NUMBER: 015601478

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with section cited above by having gardening and construction supplies in the backyard and leaving dishes on counter top which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/23/2025
Plan of Correction
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The Administrator will clean up the kitchen and backyard and submit photo proof to CCL by POC date.
Type B
Section Cited
CCR
87303(f)(1)
Maintenance and Operation
(f) All waste shall be located, stored, and disposed of in a manner that will not transmit communicable diseases or odors, pose a risk to health and safety, or provide a breeding place or food source for insects or rodents. (1) All containers storing waste shall be in good repair, free of leaks, and emptied in a timely manner.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having garbage can without lid which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/23/2025
Plan of Correction
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The Administrator will purchase garbage cans with lid and submit photo proof to CCL 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.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Luisa Fontanilla
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2025


LIC809 (FAS) - (06/04)
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