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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530161
Report Date: 01/26/2026
Date Signed: 01/26/2026 12:22:14 PM

Document Has Been Signed on 01/26/2026 12:22 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ST. THERESE CARE HOMEFACILITY NUMBER:
365530161
ADMINISTRATOR/
DIRECTOR:		CATACUTAN, ELISEO BFACILITY TYPE:
740
ADDRESS:6410 EL REPOSO STTELEPHONE:
(949) 361-8968
CITY:JOSHUA TREESTATE: CAZIP CODE:
92252
CAPACITY: 20CENSUS: 11DATE:
01/26/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:House Manager Rico PaguioTIME VISIT/
INSPECTION COMPLETED:
12:35 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Sarina Ramirez and Eldin Serrano made an unannounced visit to the facility to conduct a required annual inspection. LPAs met with House Manager Rico Paguio, and discussed the purpose of the visit.

The facility is a Residential Care Facility for the Elderly (RCFE) with a license capacity of (20), a current census of (11). LPAs conducted an overall inspection of the facility, which included, but was not limited to, the following:

Physical Plant/Environment: Indoor and outdoor passageways are free of obstruction.The facility does not have a swimming pool or similar bodies of water. The facility is enclosed and gated, however both sides remain locked, deficiency issued. The facility has sufficient lighting and is maintained at a comfortable temperature at 73 degrees F. The facility has sufficient indoor and outdoor space for resident activities. The facility is equipped with operating smoke detectors/carbon monoxide alarms last checked by Pro Security Systems on 01/15/26, working laundry equipment, and telephone service. Resident’s showers, toilets, and hand washing areas were operating properly. The hot water temperature in three (3) bathrooms measured between 105.4 and 113 degrees F. Seven (7) resident’s bedrooms had beds, bed linen, chairs, dresser, storage space and sufficient lighting. The facility has sufficient linens, towels, and personal hygiene items for residents. The facility has posted in a common area, facility license, administrator certificate, facility sketch, emergency telephone numbers, monthly menu, monthly activities, personal rights, Admissions Agreement, CCLD complaint poster, and Ombudsman poster.


Continuation on LIC – 809C:
NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Sarina Ramirez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2026
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 9
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 01/26/2026 12:22 PM - It Cannot Be Edited


Created By: Sarina Ramirez On 01/26/2026 at 11:36 AM
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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ST. THERESE CARE HOME
FACILITY NUMBER: 365530161

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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, interview, and record review, the licensee did not comply with the section cited above by not having the kitchen knives locked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/27/2026
Plan of Correction
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House Manager immediately locked knives, Administrator will conduct training to all staff understanding the regulation and provide proof with signatures to LPA by POC due 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.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Sarina Ramirez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/26/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/26/2026 12:22 PM - It Cannot Be Edited


Created By: Sarina Ramirez On 01/26/2026 at 11:36 AM
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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ST. THERESE CARE HOME
FACILITY NUMBER: 365530161

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
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:

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 by Administrator having an incomplete file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/01/2026
Plan of Correction
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Administrator will submit health screening with TB results, CPR certificate, and trainings to LPA by POC due date.
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above by punching medication's and transferring them into a clear container which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/01/2026
Plan of Correction
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Administrator will conduct a training with staff and statement of understanding medication can not be transferred from it's originally container.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Sarina Ramirez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/26/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/26/2026 12:22 PM - It Cannot Be Edited


Created By: Sarina Ramirez On 01/26/2026 at 11:36 AM
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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ST. THERESE CARE HOME
FACILITY NUMBER: 365530161

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(c)(1)
(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: (1) There is written direction from a physician, on a prescription blank, specifying the name of the resident, the name of the medication, all of the information specified in Section 87465(e), instructions regarding a time or circumstance (if any) when it should be discontinued, and an indication of when the physician should be contacted for a medication reevaluation.

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 not providing R1's mediation refusal notes to physician which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/01/2026
Plan of Correction
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Administrator will provide documentation to LPA of R1's physician contact about medication refusal by POC due 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.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Sarina Ramirez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/26/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2026


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 01/26/2026 12:22 PM - It Cannot Be Edited


Created By: Sarina Ramirez On 01/26/2026 at 11:36 AM
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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ST. THERESE CARE HOME
FACILITY NUMBER: 365530161

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

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 by not conducting quarterly disaster drills which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/02/2026
Plan of Correction
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Administrator will conduct disaster drills with residents and staff and provide proof to LPA by POC due date and continue to conduct drills quarterly.
Type B
Section Cited
HSC
1569.695(f)(2)(D)
Other Provisions
(f) A facility shall have both of the following in place: (2) A set of keys available to facility staff on each shift for use during an evacuation that provides access to all of the following: (D) All facility cabinets and cupboards or files that contain elements of the emergency and disaster plan, including, but not limited to, food supplies and protective shelter supplies.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above by not having emergency food supply which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/02/2026
Plan of Correction
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Administrator will purchase a supply of emergency food for 72 hours in an event of an emergency, and provide proof of purchase (photo and receipt) to LPA by POC due 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.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Sarina Ramirez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/26/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/26/2026 12:22 PM - It Cannot Be Edited


Created By: Sarina Ramirez On 01/26/2026 at 11:36 AM
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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ST. THERESE CARE HOME
FACILITY NUMBER: 365530161

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) Licensees that lock exterior doors or perimeter fence gates shall meet the following initial and continuing requirements: (2) The licensee shall ensure that the fire clearance includes approval of locked exterior doors or perimeter fence gates and that facility staff on all shifts have access to, and know how to use, equipment needed to unlock exterior doors or perimeter fence gates.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation,interview,record review, the licensee did not comply with the section cited above by locking both side gates which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/01/2026
Plan of Correction
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House manager unlocked both side gates, Administrator will review regulation and provide understanding that side gates must remained unlocked at all times to LPA by POC due that
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Sarina Ramirez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/26/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2026


LIC809 (FAS) - (06/04)
Page: 7 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ST. THERESE CARE HOME
FACILITY NUMBER: 365530161
VISIT DATE: 01/26/2026
NARRATIVE
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Food Service: Facility kitchen and dining area are maintained clean. The facility has sufficient non-perishable and perishable food supply for residents in care, however the facility does not have emergency food supply, deficiency issued. Chemicals were kept locked and inaccessible to residents in care, however the sharps were not locked, deficiency issued.

Care & Supervision: Facility has 24-hour/7days a week care staff.



Medical Related Services: Resident’s medications are labeled and centrally stored in a locked cabinet. Four (4) residents medications were audited at random, R1's medication was being signed off as given, however the medication was not taken by R1, deficiency issued.

Record Review: Five (5) Staff files reviewed were observed to be incomplete, Administrator's file was incomplete; deficiency issued. Four (4) Resident files reviewed were observed to be complete.

Based on observations and record review technical assistance/violations and deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report along with LIC 809D, LIC 9102, and Appeal Rights were discussed and provided to House Manager Rico Paguio at the conclusion of the visit.

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Sarina Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2026
LIC809 (FAS) - (06/04)
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