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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201136
Report Date: 07/29/2023
Date Signed: 07/29/2023 02:37:32 PM

Document Has Been Signed on 07/29/2023 02:37 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:
07/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Juliet PacaldoTIME COMPLETED:
03:00 PM
NARRATIVE
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On this day at around 9:35 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct an annual required inspection. LPA was met by staff Kester Orendain. LPA informed Orendain about the purpose of the visit. Administrator Juliet Pacaldo arrived at around 10 am.

The facility has an approved fire clearance for 11 non ambulatory and 3 bedridden residents. The facility has an approved hospice waiver for 4 residents. LPA observed 3 staff working during the visit.

During the visit, LPA inspected the facility inside and out including but not limited to resident rooms, bathrooms, living/dining area, kitchen and backyard. Passageways were observed clear and free from obstruction. There was sufficient lighting. Fire extinguisher appeared to be full and with a tag date 1/16/2023. Smoke detectors are interconnected. There was sufficient supply of perishable and non perishable foods.

At around 10:30 am, LPA reviewed 5 staff and 5 resident files.

The following deficiencies were observed:
  • at around 9:40 am, hot water measured at 143 degrees Fahrenheit in the kitchen.
  • at around 9:46 am, LPA observed insulin in the refrigerator for a resident who passed away
  • no nonskid mat in the bathroom floor
  • wall in shower area with crack
  • cranked toilet tank cover
  • no carbon monoxide observed
***continuation on Lic 809 C***
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 07/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: PACALDO-YEE
FACILITY NUMBER: 019201136
VISIT DATE: 07/29/2023
NARRATIVE
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Staff and resident interviews were conducted at around 1:20 PM.

Deficiencies were cited per Title 22 California Code of Regulations (refer to Lic 809D).

Exit interview was conducted and Appeal Rights was provided to staff Kester Orendain who was authorized by Administrator to sign the report.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 07/29/2023 02:37 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 07/29/2023 at 02:11 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: 07/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in not having carbon monoxide at the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2023
Plan of Correction
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By POC date, Administrator will install carbon monoxide and submit photo proof to CCL.
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having hot water at 143 degrees Fahrenheit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2023
Plan of Correction
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Administrator will adjust hot water within range within 24 hours and send CCL self-certification of completion.
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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 07/29/2023 02:37 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 07/29/2023 at 02:11 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: 07/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, facility failed to maintain resident common bathroom in good repair which poses/posed a potential health, safety or personal rights risk to persons in care. Toilet tank cover and wall in the shower area have cracks.
POC Due Date: 08/18/2023
Plan of Correction
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By POC date, Administrator will get the shower area fixed and send to CCL photo proof.
Type B
Section Cited
CCR
87303(e)(5)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in not having non skid mats in the bathroom which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2023
Plan of Correction
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By POC date, Administrator will replace all mats in the bathroom with non skid mats and submit photo proof to CCL.
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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2023


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Document Has Been Signed on 07/29/2023 02:37 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 07/29/2023 at 02:21 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: 07/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87633(i)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in failing to dispose former resident's medications who passed away which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2023
Plan of Correction
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By POC date, Administrator will review section cited and submit to CCL certificate of understanding of deficiency cited.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2023


LIC809 (FAS) - (06/04)
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