374602735-10-20-2023-08-AS-CLOZ-CWSRL3-20231020130627

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374602735
Report Date: 10/20/2023
Date Signed: 10/20/2023 01:07:52 PM

Document Has Been Signed on 10/20/2023 01:07 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 HOME		FACILITY NUMBER:	374602735
ADMINISTRATOR:	PANGAN, JOSE V, JR		FACILITY TYPE:	735
ADDRESS:	1607 CAITHNESS DRIVE		TELEPHONE:	(619) 428-2913
CITY:	SAN YSIDRO	STATE: CA	ZIP CODE:	92173
CAPACITY: 6		CENSUS: 2	DATE:	10/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Eliza Pangan, Administrator		TIME COMPLETED:	01:18 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced required Annual Inspection. The facility file was reviewed prior to the visit. LPA Lopez identified herself, was granted entry by caregiver Victor Panlilio. LPA discussed the purpose of the visit with caregiver Panlilo. Administrator Eliza Pangan later arrived and joined the visit. According to the facility’s license, there may be a maximum of six (6) developmentally disabled adults all of whom may be non-ambulatory in bedrooms 1, 3, 4 and 5 only at any given time at the facility site. The facility is approved for 1 bedridden client. During today’s inspection, the facility’s current census is 2 clients living at the facility. One (1) client was present at the facility site during the inspection. LPA, accompanied by caregiver Panlilo, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and activities. There was at least 2 days of perishable food, and at least 7 days non-perishable food present. Cooking/dining equipment and utensils were present all safely stored. There were no toxic chemicals/poisons accessible to clients. Medications were labeled, as required, and stored in a locked cabinet. No pools or bodies of water on the premises. Per Administrator, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were present. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. [CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: PANGAN HOME	FACILITY NUMBER: 374602735
	VISIT DATE: 10/20/2023

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[CONTINUED FROM LIC 809]

LPA interviewed staff and client, and reviewed multiple client records and staff file. During today’s visit, one client was off-site at a day program, but one was on the facility premise and was interviewed. LPA interviews did not raise any licensing concerns. The files which LPA reviewed contained required documents. Confidential records were stored in locked area.

There were no deficiencies observed or cited during today's annual inspection.

An exit interview was conducted with Administrator Pangan to whom a copy of this report along with the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit. The signature below confirms the documents were received.

LPA requested Administrator Pangan to submit a current Designation of Administrative Responsibility LIC 308, and Personnel Report LIC 500 to the licensing office within 10 business days. The facility had an updated Emergency Disaster Plan LIC 610-E on file. Forms are available at www.ccld.ca.gov.

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

LIC809 (FAS) - (06/04)

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