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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201136
Report Date: 05/09/2024
Date Signed: 05/09/2024 05:10:41 PM

Document Has Been Signed on 05/09/2024 05:10 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/
DIRECTOR:		PACALDO, JULIETFACILITY TYPE:
740
ADDRESS:999 TORRANO AVETELEPHONE:
(650) 393-0265
CITY:HAYWARDSTATE: CAZIP CODE:
94542
CAPACITY: 14CENSUS: 10DATE:
05/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Juliet Pacaldo, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:20 PM
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On this day at around 12:30 pm, Licensing Program Analyst (LPA) K. Nguyen 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 was not available and gave verbal permission for Jacob Pacaldo assistance administrator to sign the report. Administrator arrived later at 4:15pm to sign the report.

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. Smoke detectors are interconnected. First aid kit was observed to be complete.

***continuation on Lic 809 C***
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2024
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 2
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: 05/09/2024
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At 3pm LPA reviewed 3 staff and 5 resident files.

The following deficiencies were observed:

· at around 12:51pm, LPA observed expired can goods/ food inside the cabinets and refrigerator.
· at around 12:55pm, LPA observed unlock medication are left in the cabinet, and in refrigerator. LPA observed unlocked over the counter medication in resident’s room.
· at around 1:40 pm, hot water measured at 130.3 degrees Fahrenheit residents shared bathroom.
· Kitchen vent is in disrepair, and ceiling wall area observed crack.
· LPA observed 3 Oxygen tanks without a stand and not secured
· LPA observed 3 staff rooms in garage, separated by one door and two wall dividers are being alternated without a permit.
· at around 3pm LPA reviews staff records 1 out of 3 do not have CPR and First Aid certificate on file
· at around 3:30pm LPA reviews resident records 2 out of 5 residents do not have Admission Agreement and Physician Report on files

Due to time limitation LPA will return and complete the annual inspection.

A copy of this report provided via email.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024
LIC809 (FAS) - (06/04)
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