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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201136
Report Date: 08/05/2022
Date Signed: 08/05/2022 05:03:25 PM

Document Has Been Signed on 08/05/2022 05:03 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: DATE:
08/05/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Tess Cruz, co-ownerTIME COMPLETED:
05:15 PM
NARRATIVE
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On 8/5/2022, Licensing Program Analyst (LPA) L. Ibo conducted a health and safety check as a result of department receiving a priority 1 complaint. LPA met with S3, LPA called Administrator Juliet Pacaldo. Tess Cruz (co-owner) arrived at the facility at around 11:40AM . Facility has census of 10.

During the health and safety check, LPA toured the building inside and outside with S3, including but not limited to common areas, bathrooms, bedrooms and outdoor area. Facility had covid19 positive, last positive case 7/22/2022. LPA observed smoke detectors and carbon monoxide detector throughout facility. LPA observed sufficient food supplies for residents in care.

LPA observed the following:

· S7 is not fingerprint cleared and need fingerprint exemption clearance, S7 works at night shift

· Fire door and resident door was blocked with hospital beds and wheelchair

Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within 12-month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed Tess Cruz - Yee.



Exit interview conducted and appeal rights copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 08/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2022
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 2
Document Has Been Signed on 08/05/2022 05:03 PM - It Cannot Be Edited


Created By: Leslie Ibo On 08/05/2022 at 02:52 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: 08/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/06/2022
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 is not met as evidence by:
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Cleared and corrected during LPA visit.
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Based on interviews conducted facility staff failed to ensure that passageways are free from obstruction, LPA observed two bedroom doors that are located at the balcony was blocked, which poses a immediate risk to the health and safety of resident under care.
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$500.00 Civil penalty was assessed.
Type A
08/06/2022
Section Cited
CCR87355(e)(1)

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Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
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LPA informed S2 that staff (S7) cannot work at the facility until she is fingerprint cleared.

S2 stated that S7 will not be on the schedule starting tonight. Cleared
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Based on interviews conducted and records reviewed, S2 stated that S7 worked last night, LPA confirmed that S7 do not have fingerprint clearance and needs approve exemption request, which poses a immediate risk to the health and safety of resident under care.
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$500.00 Civil penalty was assessed.
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Leslie Ibo
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2022


LIC809 (FAS) - (06/04)
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