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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201136
Report Date: 09/06/2022
Date Signed: 09/06/2022 02:19:47 PM

Document Has Been Signed on 09/06/2022 02:19 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: 11DATE:
09/06/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Juliet Pacaldo, Administrator
Jay Pacaldo, Staff (S1)		TIME COMPLETED:
03:15 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 09/06/22 at 2PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced case management visit and explained the purpose of the visit with staff (S1) and administrator who authorized S1 to act on her behalf and sign the reports.

During the health and safety check, LPA observed a total of 3 staff wearing face masks and 11 residents at the facility. COVID screening was done by staff at the front entrance with no touch temperature probe, visitor's logs, hand sanitizers and additional face masks & gloves available on the screening station.

LPA toured facility with S1, including but not limited to bedrooms, kitchen, bathroom, and common areas. LPA observed resident (R1) relaxing in the visitation area with 2 other residents. LPA observed R1 did not have any swollen eyes or any marks on his face. Residents in care appear to be safe and there are no imminent health/safety concerns on today's date.

No deficiencies cited during the health and safety check. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 09/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2022
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 1