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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201136
Report Date: 10/12/2022
Date Signed: 10/12/2022 05:22:41 PM

Document Has Been Signed on 10/12/2022 05:22 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:
10/12/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:35 PM
MET WITH:Mary Joy Pacaldo, Administrative assistantTIME COMPLETED:
05:00 PM
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On 10/12/2022 at 3:35PM, Licensing Program Analyst (LPA) L. Ibo conducted an unannounced case management visit due to incident report received on 10/11/2022, R1 inappropriately touched R2’s leg. LPA met with staff Mary Pacaldo, Administrative Assistant.

LPA toured facility with S1, including but not limited to bedrooms, kitchen, bathroom, and common areas. LPA observed five (5) residents at the living room watching TV and other residents are in their own rooms.

LPA interviewed R2; R2 stated that facility address the issue with R1. R2 was moved to different room although she doesn't feel like it is necessary to move her to a different room, R2 stated she understood the decision that was made. R2 stated that she feels safe at the facility. R2 stated that her and R1 were friends before the incident happened.

Administrator stated that she called R1's doctor to get new assessment for R1. Based on interview this is R1's new behavior.

No deficiencies cited during the visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2022
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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