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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201136
Report Date: 04/21/2022
Date Signed: 04/21/2022 04:42:55 PM

Document Has Been Signed on 04/21/2022 04:42 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-YEE S CORPORATIONFACILITY NUMBER:
019201136
ADMINISTRATOR:TBDFACILITY TYPE:
740
ADDRESS:999 TORRANO AVETELEPHONE:
(650) 393-0265
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 14CENSUS: 9DATE:
04/21/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Juliet Pacaldo, ApplicantTIME COMPLETED:
03:50 PM
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
On 4/21/22 at 1-20 PM, Licensing Program Analysts (LPAs) C. Lin and L. Fici arrived unannounced to conduct Pre-licensing Required inspection for changing of ownership. LPAs met with applicant, Juliet Pacaldo and explained the purpose of the visit. The facility currently has 9 residents.

LPAs toured facility including but not limited to 7 bedrooms, 3 bathrooms, kitchen, common areas and backyard. Bedrooms and living rooms were equipped with the proper furniture. Bathrooms were equipped with grab bars and non-skid mats. Linens and hygiene supplies were observed inside cabinets. There is sufficient lighting throughout facility. Room temperature was maintained at 70 degrees F. Smoke detectors and carbon monoxide were operational. Fire extinguisher was last serviced on 12/12/2021.

Prior to licensure, the following shall be corrected and submitted to CCL by 04/29/2022.

  • Hot water temperature was 129 degrees F.
  • First-aid kit was not completed.
  • Laundry detergent and cleaning supplies were observed unlocked in the laundry room.
  • Medication was observed unlocked in two residents' room and kitchen.
  • Knives and scissor were observed unlocked in the kitchen
  • A broken dresser was observed in one of the bedrooms
  • Alarm needs to be installed in the exit door to backyard

Issues were noted during inspection. LPAs observed that facility is not ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAU. Additional requirements may still be required.

Exit interview conducted with applicant and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE: DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/21/2022
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 9