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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602735
Report Date: 10/05/2023
Date Signed: 10/05/2023 12:30:37 PM

Document Has Been Signed on 10/05/2023 12:30 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:PANGAN HOMEFACILITY NUMBER:
374602735
ADMINISTRATOR:PANGAN, JOSE V, JRFACILITY TYPE:
735
ADDRESS:1607 CAITHNESS DRIVETELEPHONE:
(619) 428-2913
CITY:SAN YSIDROSTATE: CAZIP CODE:
92173
CAPACITY: 6CENSUS: 2DATE:
10/05/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:administrator Eliza PanganTIME COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Genn Macaoile, Care Giver. Administrator Eliza Pangan later joined LPA Rodgers to discuss the visit.

Today's visit was in response to licensee’s self-reported death of Client #1 (C1), received at the CCLD San Diego Regional Office on 10/3/2023 [See LIC 811 Confidential Names List for a description of C1]. Per the report, C1 passed away on 10/3/2023.

LPA instructed Administered Pangan to obtain a copy of the death certificate and send a copy to Community Care Licensing as soon as it can be obtained. Per Regulation 80061(b)(1)(B)(1): “The licensee shall obtain a certified copy of the client's death certificate as soon as it is available, maintain it in the client's file, and shall send a copy to the Department as soon as it is obtained.”


LPA performed a facility tour / welfare check on remaining clients, collected pertinent records, and interviewed relevant staff. No deficiencies were observed or cited during today's visit.

An exit interview was conducted with Administrator Eliza Pangan, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE: DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/05/2023
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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