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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602736
Report Date: 11/18/2024
Date Signed: 11/18/2024 10:59:41 AM

Document Has Been Signed on 11/18/2024 10:59 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 2FACILITY NUMBER:
374602736
ADMINISTRATOR/
DIRECTOR:
PANGAN, JOSE V, JRFACILITY TYPE:
735
ADDRESS:1626 ANTARES DRIVETELEPHONE:
(619) 428-2913
CITY:SAN YSIDROSTATE: CAZIP CODE:
92173
CAPACITY: 6CENSUS: DATE:
11/18/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Samantha Arevalo, CaregiverTIME VISIT/
INSPECTION COMPLETED:
11:05 AM
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Licensing Program Analyst (LPA), Carmen Lopez, conducted an unannounced case management visit for the health and safety of clients. LPA Lopez identified herself and was granted entry by caregiver Samantha Arevalo. LPA Lopez stated the purpose of the visit and reviewed the basic elements of the visit with caregiver Arevalo. Administrator Eliza Pangan arrived during the visit and briefly spoke with LPA as they were on their way to an appointment for another client.

This visit was in response to an Unusual Incident/Injury Report (IR) that was received at the San Diego Regional Office on Friday, November 15, 2024. The IR stated that client had awoken with a swollen left cheek. Staff notified the Administrator who informed SDRC and contacted the clients Dentist and was able to obtain an emergency appointment. According to the results, client had 2 fractured teeth and a broken infected molar. Client does have an upcoming dental appointment.

During today's visit LPA Lopez spoke with staff and requested and obtained relevant documents pertinent to this incident. LPA Lopez observed that clients were being picked-up for program. During this time client #1 (C1) had already left to program. There were three clients during the time of the visit who were also picked-up by their respective day programs during the visit. According to the Administrator, C1 was asked if they had any issues with their teeth and they denied any pain or issues. Administrator said that the C1 only felt pain that morning when they awoke with the swelling. They were unaware how the C1 obtained the fractures as they are pretty calm at home and at their respective program.

No deficiencies were cited during today’s visit.

An exit interview was conducted with caregiver Samantha Arevalo, and a copy of this report, LIC811 and Licensee Appeal Rights (LIC9058) were provided at the conclusion of the visit. The signature below confirms that the documents were received.
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2024
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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