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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005932
Report Date: 04/24/2024
Date Signed: 04/24/2024 03:21:30 PM

Document Has Been Signed on 04/24/2024 03:21 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:A MOTHER THERESA CAREFACILITY NUMBER:
306005932
ADMINISTRATOR/
DIRECTOR:		PAO, WESLEYFACILITY TYPE:
740
ADDRESS:16192 CAIRO CIRCLETELEPHONE:
(714) 792-0967
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY: 6CENSUS: 6DATE:
04/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Maruja Camilon
Wesley Pao		TIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA was greeted and granted entry by Staff Arnel Lorica. LPA met with Staff Maruja Camilon and explained the purpose of the inspection. Administrator (AD) Wesley Pao was contacted by phone and arrived at approximately 11:55 a.m.

During the inspection LPA and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, garage and observed the following:

This is a one-story home with five resident bedrooms, one staff bedroom, three bathrooms, and attached two-car garage. All resident bedrooms had the required furnishings. LPA observed all resident beds had linens and blankets. LPA observed all windows were screened. The backyard has a shaded sitting area. LPA observed residents watching television in the living room and resting in their respective bedrooms. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested between 124.5-126.6 F degrees; a Deficiency was cited on today’s date. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. Food menu was also posted and visible. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Electric stove, microwave, washer, and dryer were all inspected and observed to be operable. Sharps were observed locked in a kitchen drawer. All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents. Medication cabinet was observed to be locked. LPA reviewed six resident files and three staff files. Four out of six resident files did not have an appraisal dated in the last twelve months; a Deficiency was cited on today’s date. Staff files did not contain any documentation for initial 6 hours of hands-on required medication training. AD stated training was conducted upon hire but was not originally documented. One out of three staff files did not contain the 20 hours of annual staff training required; two additional Deficiencies were cited on today’s date. LPA interviewed three residents and two staff. (Cont. LIC809-C)

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/24/2024
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 5
Document Has Been Signed on 04/24/2024 03:21 PM - It Cannot Be Edited


Created By: Claudia Gutierrez On 04/24/2024 at 01:39 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: A MOTHER THERESA CARE
FACILITY NUMBER: 306005932

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(3)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs.

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 two resident bathrooms, which poses a potential safety risk to persons in care.
POC Due Date: 05/24/2024
Plan of Correction
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AD stated water temperature will be maintained between 105 and 120 degrees F in lieu of warning signs. AD stated they will maintain a water temperature log to ensure water temperature is maintained between 105 and 120 degrees F and provide LPA with proof via email by POC date.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, AD interview, and record review, the licensee did not comply with the section cited above in as one out of three staff files did not contain the 20 hours of annual staff training required, which poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 05/24/2024
Plan of Correction
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AD stated staff will complete the 20 hours of annual training required, eight of which will be dementia care training. AD stated they will provide LPA with proof via email 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:Armando J Lucero
LICENSING EVALUATOR NAME:Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2024


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 04/24/2024 03:21 PM - It Cannot Be Edited


Created By: Claudia Gutierrez On 04/24/2024 at 01:39 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: A MOTHER THERESA CARE
FACILITY NUMBER: 306005932

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.69(a)(2)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, AD interview, and record review, the licensee did not comply with the section cited above, as staff files did not contain any documentation for initial 6 hours of hands-on shadowing training, which poses a potential health and safety risk to persons in care.
POC Due Date: 05/24/2024
Plan of Correction
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AD stated training would be re-done and documented and a copy provided to LPA via email by POC date.
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to:

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 four out of six resident files, which poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 05/24/2024
Plan of Correction
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AD stated that reappraisals would be completed for all four residents and will be updated, in writing, as frequently as neccessary to note significant changes and to keep appraisal accurent. AD stated they will provide LPA with copy of updated appraisals via email 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:Armando J Lucero
LICENSING EVALUATOR NAME:Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2024


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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: A MOTHER THERESA CARE
FACILITY NUMBER: 306005932
VISIT DATE: 04/24/2024
NARRATIVE
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Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024
LIC809 (FAS) - (06/04)
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