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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600099
Report Date: 02/15/2024
Date Signed: 02/15/2024 03:40:07 PM

Document Has Been Signed on 02/15/2024 03:40 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: 4DATE:
02/15/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
02:27 PM
MET WITH:Rosemarie Palaoag, Caretaker TIME COMPLETED:
03:45 PM
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On February 15, 2024, Licensing Program Analyst(LPA) John Calandra, arrived at the facility at 2:27 PM to complete the Annual Inspection. LPA Calandra met with Rosemarie Palaoag, Caretaker and explained the purpose of his visit. LPA called the Administrator, Melanie Bumanglang on the phone but was unable to get a hold of her.

LPA Calandra reviewed 2 staff files. Both were observed to be complete.

LPA Calandra interviewed 1 staff member, Rosemarie Palaoag.

A review of Centrally stored medications indicated that medications for residents were properly labeled with instructions on dosage and times of day and matched the Centrally Stored Medication Records(CSMR) kept at the facility.

No deficiencies were cited during today's visit. This report was reviewed with Rosemarie Palaoag, Caretaker and a copy of the report left at the facility.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2024
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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