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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602736
Report Date: 10/13/2022
Date Signed: 10/13/2022 11:02:15 AM

Document Has Been Signed on 10/13/2022 11:02 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:PANGAN HOME 2FACILITY NUMBER:
374602736
ADMINISTRATOR:PANGAN, JOSE V, JRFACILITY TYPE:
735
ADDRESS:1626 ANTARES DRIVETELEPHONE:
(619) 428-2913
CITY:SAN YSIDROSTATE: CAZIP CODE:
92173
CAPACITY: 6CENSUS: 5DATE:
10/13/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Eliza Pangan-Kloster, AdministratorTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Carmen Lopez and County of San Diego Nurse Contractor, Sandra Brackman, with the HAI Program, conducted an on-site HAI assessment visit. LPA and team identified themselves and discussed the purpose of today’s visit with Administrator Eliza Pangan-Kloster.

The Department conducted an on-site visit to provide technical assistance and to evaluate the facility's mitigation plan to include disinfection, testing, vaccination, and screening protocols as well as the use of personal protective equipment (PPE). During today's visit, the team interviewed the Administrator, conducted a walk-though of the facility, and provided PPE demonstration. A debriefing was conducted with the Administrator at the conclusion of the visit.

During today's visit, no deficiencies were cited. An exit interview was conducted with the Administrator to whom a copy of this report, along with Licensee Rights (LIC 9058 3/22), were provided at the conclusion of the visit. The signature below serves the documents were received.
SUPERVISORS NAME: Rebecca Hedgecock
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2022
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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