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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200577
Report Date: 09/11/2026
Date Signed: 09/11/2026 03:32:53 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/11/2026 03:32 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:SANTA TERESA CARE HOMEFACILITY NUMBER:
079200577
ADMINISTRATOR/
DIRECTOR:		CALAMBRO, MARIVEL NFACILITY TYPE:
740
ADDRESS:10 SANTA TERESA CTTELEPHONE:
(925) 261-9397
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY: 6CENSUS: 4DATE:
09/11/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:50 PM
MET WITH:George Estrella, CaregiverTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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On 09/11/2026 at 12:50PM, Licensing Program Analyst (LPA) L. Hall conducted an unannounced annual required inspection. LPA met with caregiver, Elaine Francisco, and explained the purpose of the visit. The administrator, Back up Administrator, Henry Sevilla, arrived at 1:30pm. Fire clearance was approved for five (5) non-ambulatory and one (1) bedridden, and one (1) hospice resident.

LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of six (6) bedrooms. One (1) bedroom occupied by staff. All outdoor and indoor passageways are kept free of obstruction. A comfortable temperature is maintained at 80 degrees F. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 103.7 degrees F. Residents’ bathrooms are equipped with grab bars. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 08/19/2025. Emergency Disaster Plan was last reviewed on 08/24/2026. First aid kit was observed to be complete. Fire drill was last conducted on 07/10/2025.

Continued on LIC809.
Harpreet Humpal
Laura Hall
DATE: 09/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2026
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 8
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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: SANTA TERESA CARE HOME
FACILITY NUMBER: 079200577
VISIT DATE: 09/11/2026
NARRATIVE
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Continued from LIC809C.

LPA reviewed four (4) client records and two (2) of five (5) staff records. Two (2) staff did not have a record to review.

LPA requested the following documents to be submitted to CCLD by 9/18/2026.
  • LIC 308 Designation of Administrative Responsibility
  • LIC 500 Personnel Report
  • LIC 610E Emergency Disaster Plan (last page)
  • Liability Insurance


LPA observed the following deficiencies:
  • At 1:00pm, LPA observed S5 was not fingerprinted or associated to the facility.
  • At 1:15pm, during record review LPA observed R1 and R3 did not have an updated medical assessment.
  • At 1:38pm, LPA observed during record review R2, R5, and R6 did not have a personnel file to review.
  • At 1:38pm, LPA observed the five (5) staff record reviewed did not have a first aid or CPR certification.
  • At 1:45pm, LPA observed patio door from kitchen did not have a screen.

Continued on LIC809C.


NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Laura Hall
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2026
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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: SANTA TERESA CARE HOME
FACILITY NUMBER: 079200577
VISIT DATE: 09/11/2026
NARRATIVE
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Continued from LIC809C.
  • At 1:50pm, LPA observed R1 had a half-bed rail, but no doctor's order.
  • At 1:55pm, LPA observed fire extinguisher was last serviced on 8/19/2025.
  • At 1:58pm, LPA observed during record review the last fire drill conducted was 7/10/2025.


*An immediate civil penalty of $750.00 will be assessed on today's date. $250.00 is for a repeat violation for 87303(c) and $500.00 for 87355(d)*

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.



Exit interview conducted. A copy appeal rights, LIC421BG, LIC421FC, and this report provided.
NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Laura Hall
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2026
LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 09/11/2026 03:32 PM - It Cannot Be Edited


Created By: Laura Hall On 09/11/2026 at 02:39 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SANTA TERESA CARE HOME
FACILITY NUMBER: 079200577

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/11/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/12/2026
Section Cited
CCR
87355(d)

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(d) All individuals subject to criminal record review shall be fingerprinted and sign a Criminal Record Statement under penalty of perjury.
This requirement was not met as evidence by:
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Administrator agreed to get S5 fingerprinted and submit a copy to CCLD by POC date.
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Based on record review S5 was not associated to the facility which poses an immediate health, safety and personal rights risk to persons in care.
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Type B
09/22/2026
Section Cited
CCR87463(h)

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(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. This requirement was not met as evidence by:
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Administrator agreed to get a medical assessment or an aappointment and submit a copy to CCL by POC date.
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Based on record review the Licensee did not comply with the section cited above in having a yearly assessment for R1 and R3, which poses a health risk to persons in care.
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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.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Laura Hall
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/11/2026 03:32 PM - It Cannot Be Edited


Created By: Laura Hall On 09/11/2026 at 02:51 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SANTA TERESA CARE HOME
FACILITY NUMBER: 079200577

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/11/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/18/2026
Section Cited
CCR
87412(a)

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(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 was not met as evidence by:
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Administrator agreed to have a complete file for R2 and R5, and submit a self-certification that it was completed to CCLD by POC date.
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Based on record review the Licensee did not comply with the section cited above in have R2 and R65personnel file available for review, which poses an potential health, safety, and personal risk to persons in care.
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Type B
09/18/2026
Section Cited
CCR87411(c)(1)

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(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
This requirement was not met as evidency by:
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The administrator agreed to get all staff first aid certified and submit certification to CCLD by POC date.
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Based on record review the Licensee did not comply with the section cited above in have all five staff first aid certified, which poses a potential health, safety, and personal risk to persons in care.
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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.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Laura Hall
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/11/2026 03:32 PM - It Cannot Be Edited


Created By: Laura Hall On 09/11/2026 at 02:57 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SANTA TERESA CARE HOME
FACILITY NUMBER: 079200577

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/11/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/18/2026
Section Cited
CCR
87303(c)

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c) All window screens shall be clean and maintained in good repair.
This requirement was not met as evidence by:
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The administrator to get a screen for the patio window and submit a photo to CCLD by POC date.
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Based on observation the Licensee did not comply with the section cited above in having a screen on the patio window from kitchen, which poses a potenetial personal rights risk to persons in care.
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Type B
09/11/2026
Section Cited
CCR87608(a)(5)

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(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. 5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet.

(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.
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Administrator agreed to obtain a doctor's order for half-rail and submit it to CCLD by POC date.
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Based on observation the Licensee did not comply with the section cited above in having a Doctor's order for half-rail for R4, which poss a potential health risk to persons in care.
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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.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Laura Hall
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/11/2026 03:32 PM - It Cannot Be Edited


Created By: Laura Hall On 09/11/2026 at 03:05 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SANTA TERESA CARE HOME
FACILITY NUMBER: 079200577

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/11/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/18/2026
Section Cited
CCR
87203

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All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
This requirement was not met as evidence by:
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Administrator agreed to get fire extinguisher serviced and submit invoice to CCLD by POC date.
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Based on observation the licensee did not get fire extinguisher serviced, which poses a potential health and safety risk to persons in care.
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Type B
09/18/2026
Section Cited
HSC1569.695(c)

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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 was not met as evidence by:
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Administrator agreed to conduct a fire drill and submit documentation to CCLD by POC date.
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Based on record review the Licensee did not comply with the section cited above in conducting a quarterly fire drill which poses a potential health and safety risk to persons in care.
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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.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Laura Hall
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2026


LIC809 (FAS) - (06/04)
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