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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005932
Report Date: 02/19/2025
Date Signed: 02/19/2025 03:26:43 PM

Document Has Been Signed on 02/19/2025 03:26 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: 5DATE:
02/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:40 PM
MET WITH:Maruja Camilon
Wesley Pao		TIME VISIT/
INSPECTION COMPLETED:
03:40 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 Maruja Camilon. Administrator (AD) Wesley Pao arrived at approximately 1:00 p.m. and the purpose of the inspection was discussed.

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. The backyard has a shaded sitting area. LPA observed three residents present, resting in their respective bedrooms. Per Staff Camilon, two additional residents were on a community outing. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested between 115.8-118.0 degrees Fahrenheit.

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. Fire extinguisher was observed to be fully charged with a service tag dated August 22, 2024. Electric stove, microwave, washer, and dryer were all inspected and observed to be operable. Toxic chemicals, cleaning solutions, and disinfectants were observed to be inaccessible to residents. Medication was observed to be centrally stored in a locked cabinet.

LPA reviewed five resident files and three staff files. Two of five resident medical assessments did not include results of examination for TB; a Deficiency was cited on today’s date. LPA interviewed two residents and two staff.

Based on the observations made during today’s inspection, one deficiency is 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: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/19/2025
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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Document Has Been Signed on 02/19/2025 03:26 PM - It Cannot Be Edited


Created By: Claudia Gutierrez On 02/19/2025 at 02:54 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: 02/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(c)(1)(A)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as two of five resident medical assessments did not include results of examination for TB, which poses a potential health risk to persons in care.
POC Due Date: 03/05/2025
Plan of Correction
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AD stated TB examination results will be obtained and proof provided via email 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.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/19/2025


LIC809 (FAS) - (06/04)
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