<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294297
Report Date: 07/26/2021
Date Signed: 07/26/2021 03:57:10 PM

Document Has Been Signed on 07/26/2021 03:57 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, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:ST. THERESE HOMES, INC.FACILITY NUMBER:
435294297
ADMINISTRATOR:ZIPAGAN, SANDYFACILITY TYPE:
740
ADDRESS:985 FITZGERALD AVENUETELEPHONE:
(408) 472-2059
CITY:SAN MARTINSTATE: CAZIP CODE:
95046
CAPACITY: 6CENSUS: 5DATE:
07/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Sandy ZipaganTIME COMPLETED:
11:35 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Gladys Kuizon conducted an annual inspection today and met with Administrator Sandy Zipagan.

At 11:00 AM, LPA entered the facility through the facility's central entry point and was screened by staff. At 11:11 AM, a tour of the facility was conducted. COVID-19 postings were observed throughout the facility including bathrooms, living room, dining room, and kitchen. 5 residents and 3 staff were present during visit.

Hand sanitizers, soap, and paper supplies were observed available. At least 2 days' supply of perishable food and at least 1 week's supply on non-perishable food supply was observed in the premises. Personal protective equipment (PPE) and disinfection supplies were available in the premises.

Per Administrator, all residents and staff are fully vaccinated against COVID-19. The facility is currently accepting visitors inside the facility. The facility's mitigation plan was reviewed. Staff training records included Infection Control and Emergency Preparedness training.

Exit routes were observed clear and unobstructed. The facility is equipped with smoke detectors, fire extinguishers, and a carbon monoxide detector. A current roster of residents with emergency contact information was reviewed.

No deficiencies were cited. Exit interview conducted with Administrator and a copy of this report was provided during visit.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Gladys Kuizon
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2021
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 1