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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202787
Report Date: 12/18/2025
Date Signed: 12/18/2025 03:20:30 PM

Document Has Been Signed on 12/18/2025 03:20 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:ST. THERESE ELDERLY CARE FACILITYFACILITY NUMBER:
435202787
ADMINISTRATOR/
DIRECTOR:		BENITEZ, MICHELLEFACILITY TYPE:
740
ADDRESS:5903 CAHALAN AVETELEPHONE:
(408) 578-8068
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6CENSUS: 5DATE:
12/18/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Michelle BenitezTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced Required 1-Year inspection visit. LPA met with the Administrator, Michelle Benitez and stated purpose the visit.

The facility is licensed to serve adults 60 and over, 6 ambulatory and 6 out of 6 may be non-ambulatory and a hospice waiver for 5. The facility has a current census of 5. At the time of the visit (0800), one staff and administrator was busy assisting resident with their activities of daily living (ADLs). LPA was accompanied by the administrator during inspection of the facility inside and outside.

LPA observed exterior walkways were free from any obstruction ramps and railings. The back ramp was observed to have some signs of wear and tear. A gazebo was observed and items were stored in the gazebo, such as tables, propane gas tanks, cat scratchers, some chemicals on the table, cat food on the table, some gardening tools to name a few. LPA observed a sack of plant food/fertilizer. ADM stated the gazebo is not used by residents during winter season. In the summer time, the gazebo is cleaned and de-cluttered for resident's use.

LPA inspected the garage and laundry area, found the laundry area unlocked. Laundry detergents were observed on top of the shelves above the washer and dryer. Washer and dryer were in good working condition. The garage was organized and has a walkway that was not obstructed.

LPA inspected the interior of the facility and observed that hallways were free from obstruction and free from tripping hazard. The hallways were well lighted. 5 out of 5 resident bedrooms are sanitary and organized, furnished with dressers, chairs and tables that are sufficient to store resident's personal belongings. LPA observed that 5 Out of 5 residents are non-ambulatory, at the time of the visit 2 Out of 5 residents were awake and 3 Out of 5 were in bed resting. page 1 of 3 - continued to LIC 809 C

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: ST. THERESE ELDERLY CARE FACILITY
FACILITY NUMBER: 435202787
VISIT DATE: 12/18/2025
NARRATIVE
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LPA inspected 2 resident bathroom and found it clean, sanitary, with hygiene supplies. Bathroom were equipped with grab bars, non-slip floor, a shower chair, and a raised bathroom seat. The hot water was measured with a digital thermometer. Water temperature for both bathrooms measured at 137.6 to 139 degree F.

LPA inspected the dining area and living area and observed gifts bags the floor at the corner end of the table was piles of papers, set aside to make room for Christmas decorations. The living area has gift bags and items to be wrapped for the holiday season. The couch has gift items, and gift wrappers on top. ADM stated that they are in the process of wrapping gifts for the coming holiday to be distributed.

LPA inspected the kitchen, and observed that the kitchen was sanitary. The kitchen counter has food items such as bread, tray of 30 eggs sealed, cookies, a box of corn dog, food on top of the stove covered with glass lids, a container of meat on top of the corn dog box. A container of take out food that was eaten and left on the counter top, fresh produce on the corner left side of the kitchen counter and a crate of fresh produce on the kitchen floor (photos taken). A LPA observed an upright refrigerator/freezer combination, with 2 days of perishable items. The refrigerator temperature measured at 38 degree F and the freezer measured at 0 degree F. Water temperature measured at 133 degree F with a digital thermometer. LPA observed a drawer with the key containing the sharps and knives that was unlocked and no staff was present. LPA observed 7 days of non-perishable items.

The facility is equipped with a working smoke and carbon monoxide alarm a fire extinguisher (last inspected 09/30/2025). First aid kit with the guidebook. Emergency disaster training, fire and earthquake drill was administered on January 2025 and no subsequent drills and training were administered.

LPA reviewed 5 out of 5 resident file record and observed the following, 3 out of 5 are missing the consent form, 2 out of 5 has incomplete or missing client's personal valuables (LIC 621), 1 out of 5 is missing proof of TB testing, 2 out 5 does not have the appraisal needs and services plan, 5 out of 5 does not have the weight record. 5 Out of 5 resident record has complete and updated Centrally Stored Medication & Destruction Record (CSMDR).

LPA reviewed 3 out of 3 staff record and observed the following; 3 Out of 3 Staff are missing the SOC341A (mandated reporter) 1 out of 3 is missing the LIC 503 (health screening), 1 out of 3 training was last administered on 07/07/2024, 1 out of 3 is missing the LIC (501) personnel record/job application. page 2 of 3 - continued to LIC 809C

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2025
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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: ST. THERESE ELDERLY CARE FACILITY
FACILITY NUMBER: 435202787
VISIT DATE: 12/18/2025
NARRATIVE
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Based on observation and record review following were observed that may pose an immediate or potential risks to persons in care. The water temperature measured from 133.1 to 139.7, food safety and storage the laundry area was unlocked, laundry detergents were observed. At exterior area; gazebo contains chemicals on top of the table, gardening tools and potting soil. The ramp by the back side is showing signs of deterioration. LPA observed unlocked drawer containing knives and sharps and no staff was present in the kitchen.

LPA suggested to LIC/ADM to reach out to the department's Technical Support Program (TSP). The TSPs are non-enforcement programs of CCLD and provide services, training, and resources to support providers in meeting licensing requirements.

Deficiencies are cited during today' visit based on California Code of Regulation (CCR) Title 22, other deficiencies were issued technical violations based on what was observed and the severity of the deficiency.
(See LIC 809D).

An exit interview was conducted with licensee/administrator Michelle Benitez. A copy of the report and appeals rights were provided

end of report
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NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/18/2025 03:20 PM - It Cannot Be Edited


Created By: Maria Partoza On 12/18/2025 at 01:04 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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: ST. THERESE ELDERLY CARE FACILITY
FACILITY NUMBER: 435202787

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/18/2025

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 obsservation, the licensee did not comply with the section cited above by not maintaining faucets used by residents to deliver hot water not more than 105 degree F to 120 degree F. When measured with a digital thermometer, the water in the kitchen faucet, bathroom 1 and 2 measured at 133 to 139.7 degree F, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/19/2025
Plan of Correction
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LIC/ADM stated that he/she will submit a written plan of correction to address the water temperature not to exceed 105 to 120 degree F when measured. A written plan of correction will be submitted to LPA by 12/19/2025.
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 by not ensuring the laundry area containing cleaning solutions, and drawer containing knives and sharp objects are locked when not in use. LPA observed that the drawer with knives was kept unlock and no staff was present, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/19/2025
Plan of Correction
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LIC/ADM stated he/she will submit a written plan of correction to address the broken laundry area being kept unlocked when not in use and cleaning solutions were present. The drawer containing the knives and sharps will be address. A written plan of correction will be submitted to LPA by the POC due date of 12/19/2025
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:
Maria Partoza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2025


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 12/18/2025 03:20 PM - It Cannot Be Edited


Created By: Maria Partoza On 12/18/2025 at 01:04 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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: ST. THERESE ELDERLY CARE FACILITY
FACILITY NUMBER: 435202787

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(c)
Storage Space and Access
(c) Except as specified in subsection (d), the licensee shall implement reasonable interventions in order to ensure that nutritional supplements, vitamins, alcohol, cigarettes and other potentially toxic substances, such as certain plants, gardening supplies, and auto supplies, are stored so as not to pose a hazard to residents.

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 by not ensuring that potential toxic substances, gardening supplies placed in the gazebo and the potting soil on the pavement are stored properly so as not to pose a hazard to residents in care which poses an immediate health, safety or personal rights risk to persons in care
POC Due Date: 12/19/2025
Plan of Correction
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LIC/ADM stated he/she will submit a written plan of correction to address potential toxic substances, gardening supplies placed in the gazebo and potting soil on the pavement will be stored properly so as not to pose a hazard to residents in care. Written plan of correction will be submitted to LPA 12/19/2025.
Section Cited
Deficient Practice Statement
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3
4
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.
Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:
Maria Partoza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2025


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 12/18/2025 03:20 PM - It Cannot Be Edited


Created By: Maria Partoza On 12/18/2025 at 01:04 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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: ST. THERESE ELDERLY CARE FACILITY
FACILITY NUMBER: 435202787

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review the licensee did not comply with the section cited above by not completing appraisal needs and services plan (LIC 625) for resident 4 and 5 (R4 & R5) prior admission to determine the resident's suitability to the facility and other residents in care, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2026
Plan of Correction
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LIC/ADM stated that he/she wiil complete the appraisal needs and services plan of R4 and R5 and proof of correction will be submitted to LPA by the due date of 01/02/2026.
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 in by not ensuring R5 does not have a comunicable tuberculosis prior to admission to the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2026
Plan of Correction
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LIC/ADM stated that he she will ensure that R5 will have a TB test done to ensure that R5 does not have a communicable tuberculosis and will submit proof of testing to LPA by the POC due date of 01/02/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:
Maria Partoza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2025


LIC809 (FAS) - (06/04)
Page: 7 of 8
Document Has Been Signed on 12/18/2025 03:20 PM - It Cannot Be Edited


Created By: Maria Partoza On 12/18/2025 at 01:04 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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: ST. THERESE ELDERLY CARE FACILITY
FACILITY NUMBER: 435202787

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/18/2025

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
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in by not conducting a drill at least quarterly for each shift, for the type of emergency, that vary from quarter to quarter (fire, earthquake, emergency disasters i.e. power outages) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2026
Plan of Correction
1
2
3
4
LIC/ADM stated he/she will be conducting quarterly training to staff and if possible with resident's participation. The training will be documented and will include, the type of emergency covered by the drill and the names of the staff participating in the drill. A proof that training was administered will be submitted to LPA by the POC due date of 01/02/2026.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
1
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.
Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:
Maria Partoza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2025


LIC809 (FAS) - (06/04)
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