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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201136
Report Date: 05/10/2024
Date Signed: 05/10/2024 02:29:25 PM

Document Has Been Signed on 05/10/2024 02:29 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:
05/10/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Paula Madrigal, Co-AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:10 PM
NARRATIVE
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On this day at around 9:15 am, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct a continuation annual required inspection. LPA met with Co-Administrator, Paula Madrigal. LPA was informed by Co-Administrator that Administrator, Juliet was out of town, and will return 5/17/24.

The following deficiencies were observed:


· at around 9:30am, LPA reviewed facility files (liability insurance expired on 2/2/22).
· at around 9:40am, LPA reviewed facility files (emergency disaster plan is not up to date).
· at around 10:00am, LPA reviewed facility files (there are no record of fire trill).
· at around 10:10am, LPA reviewed facility files (facility do not have designation of administrative and staff assignments on files)
· at around 10:20am, LPA reviewed resident’s files (not having PRN medication signed, dated written order from a physician).
· At around 11:35am, LPA observed the storage room in the garage are being used for staff bedroom.

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



Exit interview was conducted and Appeal Rights was provided to Co-Administrator Paula Madrigal.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2024
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 9
Document Has Been Signed on 05/10/2024 02:29 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 05/10/2024 at 01:05 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: 05/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 hot water measured at 130.3 degrees Fahrenheit residents shared bathroom. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/11/2024
Plan of Correction
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Administrator will submit photo of hot water adjustment to CCLD by POC date.
Type A
Section Cited
CCR
87309(b)
Storage Space
(b) Medicines shall be stored as specified in Section 87465(c) and separately from other items specified in (a) above.

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 by unlock medication are left in the cabinet, and in refrigerator. LPA observed unlocked over the counter medication in resident’s roomwhich poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/11/2024
Plan of Correction
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Administrator will submit photo of all medication locked, and in a lock box to CCLD by POC date.
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:Bennett Fong
LICENSING EVALUATOR NAME:Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2024


LIC809 (FAS) - (06/04)
Page: 2 of 9
Document Has Been Signed on 05/10/2024 02:29 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 05/10/2024 at 01:05 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: 05/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(23)
General Food Service Requirements
(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures.

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 by having expired can goods/ food inside the cabinets and refrigerator. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/11/2024
Plan of Correction
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Administrator will check and verify with staff on getting rid of all expired cans good/ food to CCLD by POC date.
Type A
Section Cited
CCR
87465(h)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored:

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 by having mediation to centrally store, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/11/2024
Plan of Correction
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Administrator will submit photo of all medication of residents in one centrally stored area to CCLD by POC date.
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:Bennett Fong
LICENSING EVALUATOR NAME:Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2024


LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 05/10/2024 02:29 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 05/10/2024 at 01:05 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: 05/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87618(b)(3)(E)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (E) Oxygen tanks that are not portable shall be secured in a stand or to the wall.

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 by not having 3 Oxygen tanks without a stand and not secured, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/11/2024
Plan of Correction
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Administrator will submit photo of oxygen tanks on stand, safely secured , or remove to CCLD by POC date.
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:Bennett Fong
LICENSING EVALUATOR NAME:Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2024


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 05/10/2024 02:29 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 05/10/2024 at 01:05 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: 05/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having a current liability insurance (exp: 2/2/2022), which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/24/2024
Plan of Correction
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Administrator will submit current liability insurance to CCLD by POC date.
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, the licensee did not comply with the section cited above by kitchen vent is in disrepair, and ceiling wall area observed crack, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/24/2024
Plan of Correction
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Administrator will submit photo of kitchen vent and ceiling crack fix to CCLD by POC date.
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:Bennett Fong
LICENSING EVALUATOR NAME:Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2024


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 05/10/2024 02:29 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 05/10/2024 at 01:05 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: 05/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87305(a)
Alterations to Existing Buildings or New Facilities
Prior to construction or alterations, all facilities shall obtain a building permit.

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 by 3 staff rooms in garage, separated by one door and two wall dividers are being alternated without a permit, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2024
Plan of Correction
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Administrator will obtain and submit a building permit or tear the wall down to CCLD by POC date.
Type B
Section Cited
CCR
87308(c)
Resident and Support Services
(c) General storage space shall be maintained for equipment and supplies as necessary to ensure that space used to meet other requirements of these regulations is not also used for storage.

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 facility is using the storage room in the garage as a staff bedroom, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/17/2024
Plan of Correction
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Administrator will submit photo of the storage room is being used as a storage room, and not used as a staff bedroom to CCLD by POC date.
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:Bennett Fong
LICENSING EVALUATOR NAME:Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2024


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 05/10/2024 02:29 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 05/10/2024 at 01:05 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: 05/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by staff not have CPR and First Aid certificate on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/17/2024
Plan of Correction
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Administrator will submit all current staff CPR and First Aid Kit certifications to CCLD by POC date.
Type B
Section Cited
CCR
87465(e)
Incidental Medical and Dental Care Services
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having PRN medication signed, dated written order from a physician..., which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/24/2024
Plan of Correction
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Administrator will submit records of PRN sign and dated by physician for all resident to CCLD by POC date.
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:Bennett Fong
LICENSING EVALUATOR NAME:Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2024


LIC809 (FAS) - (06/04)
Page: 7 of 9
Document Has Been Signed on 05/10/2024 02:29 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 05/10/2024 at 01:05 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: 05/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(15)
Resident Records
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having resident admission agreement...on files, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/24/2024
Plan of Correction
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Administrator will obtaine residents admission agreement, and submit to CCLD by POC date.
Type B
Section Cited
CCR
87458(b)
Medical Assessment
(b) The medical assessment shall include, but not be limited to:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having resident physician report on files, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/24/2024
Plan of Correction
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Administrator will obtain residents physician reports and submit to CCLD by POC date.
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:Bennett Fong
LICENSING EVALUATOR NAME:Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2024


LIC809 (FAS) - (06/04)
Page: 8 of 9
Document Has Been Signed on 05/10/2024 02:29 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 05/10/2024 at 01:05 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: 05/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(a)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above by not having an emergency and disaster plan on files, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/24/2024
Plan of Correction
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Administrator will send emergency plan and disaster and submit to CCLD by POC date.
Type B
Section Cited
CCR
87212(b)(1)
Emergency Disaster Plan
(b) The plan shall be subject to review by the Department and shall include: (1) Designation of administrative authority and staff assignments.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above by not having designation of administrative and staff assignments on files, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/24/2024
Plan of Correction
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2
3
4
Administrator will submit a designation of administrative and staff assignments and submit to CCLD by POC date.
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:Bennett Fong
LICENSING EVALUATOR NAME:Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2024


LIC809 (FAS) - (06/04)
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