374602735-9-4-2024-08-AS-CLOZ-D8DUXX-20240822155904

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374602735
Report Date: 08/22/2024
Date Signed: 09/04/2024 10:22:39 AM

Document Has Been Signed on 09/04/2024 10:22 AM - 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/ DIRECTOR:	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: 3	DATE:	08/22/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:45 AM
MET WITH:	Eliza Pangan, Administrator, and Genn Macaoile, Caregiver		TIME VISIT/ INSPECTION COMPLETED:	04:10 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 Genn E. Macaoile. LPA discussed the purpose of the visit with Licensee Jose Pangan and Administrator Eliza Pangan who later arrived and joined the visit. According to the facility’s license, there may be a maximum of six (6) clients all of whom may be non-ambulatory in in bedroom 1, 3, 4 and 5 with bedroom 5 approved for a bedridden client, in at any given time at the facility site. During today’s inspection, the facility’s current census is three (3) clients living at the facility. There were two (2) clients present at the facility site during the inspection. LPA, accompanied by Administrator Pangan and caregiver Macaoile, 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. The facility’s ambient internal temperature was comfortable and compliant, at 75 degrees Fahrenheit (F). Hot water temperature at taps accessible to clients were also compliant: kitchen sinks measured hot water at 112.8 degrees F; sink in restroom #1 delivered hot water at 105.9 degrees F; sink in restroom #2 delivered hot water at 107.8; and sink in restroom #3 measured hot water at 108.7 degrees F. There was at least 2 days of perishable food, and at least 7 days non-perishable food present. Cooking and dining equipment and utensils were present, and all safely stored. There were no toxic chemicals and poisons accessible to clients. Medications were properly labeled, as required, and stored in locked cabinet. The facility-maintained medication logs which LPA reviewed. [CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024

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: 08/22/2024

NARRATIVE

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[CONTINUED FROM LIC 809]

No pools or bodies of water on the premises. Per licensee, 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 (01) and serviced within the last 12 months. First aid kits were complete and readily accessible.

LPA interviewed staff and client, and reviewed staff and client records. During today’s visit there were 2 clients on the facility premise. LPA interviews did not raise any licensing concerns. The files which LPA reviewed contained required documents. Confidential records were stored in a locked area. Required licensing postings were observed in a visible area of the facility.

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

An exit interview was conducted with Administrator Pangan and Licensee 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.

The San Diego Regional Office has current Designation of Administrative Responsibility LIC 308 and Personnel Report LIC 500 on file. LPA requested Administrator Pangan to submit a current Emergency Disaster Plan LIC 610-D to the licensing office within 10 business days. Forms are available at www.ccld.ca.gov.

SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/04/2024 10:22 AM - It Cannot Be Edited

Created By: Carmen Lopez On 08/22/2024 at 03:29 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: PANGAN HOME	FACILITY NUMBER: 374602735
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80072(a)(8)(b)

A written order from the client's physician indicating the need for postural support shall be maintained in the client's record. The licensing agency shall be authorized shall be authorized to require additional documentation if needed to verify the order. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in 1 out of 1 client did not have their PCP orders for the need of railings on file which posed a potential personal rights risk to 1 of 1 [C1] persons in care.
	POC Due Date: 09/27/2024
	Plan of Correction
1 2 3 4	Administrator will include the bedrailings to clients next PCP visit and have it on file and submit the notice for C1's need of postural support to LPA by POC due date, 09/27/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Jennifer Lott

LICENSING EVALUATOR NAME:

Carmen Lopez

LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024

LIC809 (FAS) - (06/04)

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