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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201136
Report Date: 05/05/2022
Date Signed: 05/05/2022 12:58:56 PM

Document Has Been Signed on 05/05/2022 12:58 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:
05/05/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Tessa Cruz, ApplicantTIME COMPLETED:
01:15 PM
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On 5/5/22 at 11:40 AM, Licensing Program Analysts (LPA) C. Lin arrived unannounced to conduct the 2nd Pre-licensing Required inspection for changing of ownership. LPA met with applicant, Tessa Cruz and explained the purpose of the visit. The facility currently has 9 residents.

LPA toured facility, inspected deficiencies cited on 4/21/22, and confirmed that deficiencies have been corrected. Hot water temperature was 120 degrees F.. First Aide kit was observed to be purchased. Laundry detergent and cleaning supplies were observed locked inside the laundry room. Medication, knives, and scissors were observed locked in the kitchen. A bland new dresser was replaced. Alarm was observed to be installed on both doors exit to the backyard.

Component III Orientation had been conducted previously with Juliet Pacaldo and Tessa Cruz by LPAs C. Lin and L. Fici on 4/21/22, therefore it's waived at this time.

No issues noted during inspection. LPA observed that facility is 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: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2022
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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