374602736-6-27-2024-08-AS-CLOZ-D6MV9V-20240627161457

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374602736
Report Date: 06/27/2024
Date Signed: 06/27/2024 04:15:48 PM

Document Has Been Signed on 06/27/2024 04:15 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 2		FACILITY NUMBER:	374602736
ADMINISTRATOR/ DIRECTOR:	PANGAN, JOSE V, JR		FACILITY TYPE:	735
ADDRESS:	1626 ANTARES DRIVE		TELEPHONE:	(619) 428-2913
CITY:	SAN YSIDRO	STATE: CA	ZIP CODE:	92173
CAPACITY: 6		CENSUS: 6	DATE:	06/27/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:00 PM
MET WITH:	Licensee Jose Pangan and Administrator Eliza Pangan		TIME VISIT/ INSPECTION COMPLETED:	04:25 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 Emelda Garcia. LPA discussed the purpose of the visit with caregiver Garcia. Administrator Eliza Pangan and Licensee Jose 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 at any given time at the facility site. The facility is approved for 2 bedridden clients/transfer dependent adults in bedroom #1 only. RHCP is approved. During today’s inspection, the facility’s current census is 6 clients living at the facility. LPA, accompanied by caregiver Garcia, 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 76 degrees Fahrenheit (F). Hot water temperature at taps accessible to clients were also compliant: kitchen sink measured hot water at 115.3 degrees F; sink in restroom #1 delivered hot water at 105.9 degrees F; and sink in restroom #2 delivered hot water at 119.8 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 or poisons accessible to clients. Medications were properly labeled, as required, and stored in locked cabinet which LPA inspected. 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: 06/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024

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 2	FACILITY NUMBER: 374602736
	VISIT DATE: 06/27/2024

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[CONTINUED FROM LIC 809]

No pools or bodies of water on the premises. Per Administrator Pangan, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguishers was present (01) and serviced within the last 12 months. First aid kit was complete and readily accessible.

LPA reviewed staff and client records. During today’s visit there were no clients on the facility premise, but clients later arrived at the facility during the visit. LPAs visit 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 cited during today's annual inspection.

An exit interview was conducted with Administrator Eliza Pangan and Licensee Jose 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 and Licensee Pangan to submit a current Designation of Administrative Responsibility LIC 308, to the licensing office within 10 business days. Forms are available at www.ccld.ca.gov. A copy of the updated Personnel Report LIC 500, Emergency Disaster Plan LIC 610-D, and Residential Infection Control Plan LIC 9282 (6/23) were submitted to the San Diego Regional Office.

SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024

LIC809 (FAS) - (06/04)

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