<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600099
Report Date: 01/04/2024
Date Signed: 01/04/2024 05:45:13 PM

Document Has Been Signed on 01/04/2024 05:45 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 BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:LA SALETTE HOME, LTD. IIIFACILITY NUMBER:
415600099
ADMINISTRATOR:MELANIE BUMANGLAGFACILITY TYPE:
735
ADDRESS:274 ST. CATHERINE DRIVETELEPHONE:
(650) 993-4137
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY: 6CENSUS: 5DATE:
01/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Rosemarie Palaoag, Caretaker TIME COMPLETED:
05:45 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
On January 4, 2024, Licensing Program Analyst(LPA) John Calandra, arrived at the facility to conduct an unannounced Annual 1-year required inspection. LPA Calandra met with Rosemarie Palaoag, Caretaker.

LPA Calandra toured the physical plant. This is a two story home with residents living on both floors. The facility has 5 bedrooms and 3 bathrooms. Hot water in all bathrooms was measured at 107.1 degrees Fahrenheit well within the required range of 105-120 degrees. All bedrooms were observed to have the required furniture. No accessible bodies of water were observed nor hazards in the front and back yards. Fire extinguishers were observed to be fully charged. First aid kit was observed to be complete. Facility has 2 days of required perishables and 7 days of non-perishables. No expired food was observed.

Sharp objects were observed to be locked and in-accessible to persons in care.

Ceiling in bedroom upstairs is damaged from solar panels that were recently removed from the roof per interviews with Administrator, Melanie Bumanglag and Rosemarie Palaoag. A technical violation was provided.

Soap and cleaning supplies were observed to be locked and in-accessible to persons in care.

LPA interviewed 2 residents and reviewed 5 resident files. All were observed to be complete. No staff interviews or staff file reviews were completed today.

LPA Calandra will return to the facility to complete the Annual Inspection at a later date.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE: DATE: 01/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/04/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 01/04/2024 05:45 PM - It Cannot Be Edited


Created By: John Calandra On 01/04/2024 at 04:58 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: LA SALETTE HOME, LTD. III
FACILITY NUMBER: 415600099

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.4(g)
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
This requirement is not met as evidenced by record review which showed that the licensee did not ensure to submit an exception request regarding the retention of individuals 60 years and older. The facility is not in compliance with the section cited above in 3 out of 5 clients who over age which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/11/2024
Plan of Correction
1
2
3
4
Licensee/Administrator will submit an exception request regarding the retention of individuals 60 years of age or older to the Department by the POC due date.
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:Cara Smith
LICENSING EVALUATOR NAME:John Calandra
LICENSING EVALUATOR SIGNATURE:
DATE: 01/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/04/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: LA SALETTE HOME, LTD. III
FACILITY NUMBER: 415600099
VISIT DATE: 01/04/2024
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
26
27
28
29
30
31
32
Deficiencies of the California Code of Regulations, Title 22 are cited on the LIC 809-D. Failure to correct the deficiencies may result in civil penalties.

A copy of the Report,Citation, and Technical Violation was reviewed with DSP/caretaker, Rosemarie Palaoag and left at the facility. Appeal rights were provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3