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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201136
Report Date: 07/21/2022
Date Signed: 07/21/2022 02:25:54 PM

Document Has Been Signed on 07/21/2022 02:25 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:PACALDO-YEEFACILITY NUMBER:
019201136
ADMINISTRATOR:PACALDO, JULIETFACILITY TYPE:
740
ADDRESS:999 TORRANO AVETELEPHONE:
(650) 393-0265
CITY:HAYWARDSTATE: CAZIP CODE:
94542
CAPACITY: 14CENSUS: 10DATE:
07/21/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Tessa Cruz, ManagerTIME COMPLETED:
02:35 PM
NARRATIVE
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On 7/21/2022 at 11:25 AM, Licensing Program Analyst (LPA) C. Lin arrived unannounced to conduct case management while conducting an initial 10-day complaint investigation. LPA met with staff Kester Orendain, Manager Tessa Cruz arrived at a later time.

Upon entry, LPA learned that there was 1 resident tested Covid-19 positive on 7/19/22 and exhibiting symptoms. LPA observed that the isolation room door was open. Caregiver S1 stated that they let the door open so that they could check on the resident without opening the door each time. All other resident's rooms are opened and residents didn't have mask on. LPA observed there has no set of PPE supplies by the isolation room, and no isolation signs on the door. S1 stated that PPE supplies were by the main door where they were donning and doffing. LPA observed staff did not follow infection control protocol.


The above deficiency was observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiency by POC date may result in additional Civil Penalties.

Exit interview conducted with Manager. LIC809D, Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE: DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2022
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 07/21/2022 02:25 PM - It Cannot Be Edited


Created By: Catherine Lin On 07/21/2022 at 01:22 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: PACALDO-YEE
FACILITY NUMBER: 019201136

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/22/2022
Section Cited
CCR
87470(b)(3)

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87470 Infection Control Requirements
(b) In addition to subsection (a), when one or more residents in the facility are diagnosed with a communicable disease, the following shall apply:
(3) There shall be separation and care of residents whose illness requires separation, including quarantine or isolation, from others.

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Caregiver closed the isolation room door immediately.
Administrator agreed to conduct training with staff of regulation and infection control protocol, submit training agenda with staff signature to CCL by POC due date.
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Based on observation, the licensee did not comply with the section cited above. LPA observed staff left the isolation room door open where poses an immediate health, safety or personal rights 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.
SUPERVISOR'S NAME:Bennett Fong
LICENSING EVALUATOR NAME:Catherine Lin
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2022


LIC809 (FAS) - (06/04)
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