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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600099
Report Date: 10/27/2025
Date Signed: 10/27/2025 03:06:51 PM

Document Has Been Signed on 10/27/2025 03:06 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/
DIRECTOR:		MELANIE BUMANGLAGFACILITY TYPE:
735
ADDRESS:274 ST. CATHERINE DRIVETELEPHONE:
(650) 993-4137
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY: 6CENSUS: 3DATE:
10/27/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Staff - Edwardo ManansalaTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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On 10/27/2025, Licensing Program Analyst (LPA) Vado Jaime Vado conducted an unannounced annual required inspection visit. LPA Vado met with staff person Edwardo Manansala. There are no residents present in the facility at this time as they are all in day programs.

This is a two level facility licensed for residents age range 18 - 59 years. All must be ambulatory. This is a two level facility. The physical plant was toured inside and outside of the facility to ensure the safety of the residents. There are no video cameras on inside the facility per staff. The upper floor is where the clients reside in three rooms, and the lower level is where the staff reside according to Edwardo. There are two rooms, both are observed to not have any residents. One is the staff person's room, Edwardo, and the other has two adults that are not clients, who Edwardo says are visitors who will be leaving and do not reside in the facility as they are visiting. There is a bathroom on the ground floor and garage is observed to have several refrigerators and a large drop in freezer. Present is a lot of old items not used by the facility any longer such as several non-operational full sized refrigerators and an old washer and dryer that are not functional, and other clutter that should be removed. There is a door that goes to the backyard which is observed to be cluttered with unused wooden palettes, filing cabinet, old broken and unused furniture such as tables and a light fixture, unsecured ladder, pet/animal carrier, and additional items that needs to be cleared out as this poses a health and safety risk to clients in care. LPA observed the facility kitchen. The appliances in place are observed. There is a counter top microwave that functions, refrigerator, and stove top. LPA checked the elevated oven and elevated microwave built into the wall both do not function and are storing kitchen supplies and utensils such as bowls and other items. Perishable and non-perishable food items are observed as in place. The refrigerator is observed to have food items such as half of a cantaloupe, cut pieces of cantaloupe, a pre made sandwich with a fried egg on the side, cut tomato, bowl of food, and other items that are not covered or stored correctly. Additionally in the freezer, the rack is broken and is being held up by food below the rack and the lights in the refrigerator do not work, this is a potential health and safety risk to residents in care. LPA observed multiple signs of rodent droppings in the kitchen. LPA observed droppings on the counter where the sink is located. Droppings are observed on the kitchen floors along the walls and floors and on some areas where food is stored.

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NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Jaime Vado
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2025
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 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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 BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: LA SALETTE HOME, LTD. III
FACILITY NUMBER: 415600099
VISIT DATE: 10/27/2025
NARRATIVE
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There are an additional two refrigerators in the garage that do function and house additional food supplies. First aid kit is observed as complete with required items. Medications are observed to be locked in a cabinet in a drawer located in the kitchen below the oven/stove. LPA observed at least one fire extinguisher in place which is currently within operating range with an inspection date of 04/29/2024, smoke detector, carbon monoxide detectors are observed in place through out the facility. There is a fire pull station observed by the front door on the upper level. Laundry area is also observed as fully operational on the ground floor of the facility near the garage. Emergency exit routes are observed inside and outside. LPA observed that the exit is blocked in the backyard by old furniture. This poses an immediate health and safety risk to clients. Water temperature is measured at 124F and climbing in the kitchen, which poses an immediate health and safety risk to residents in care and is considered a repeat violation, with a civil penalty in the amount of $1000. LPA observed all client rooms on the upper floor. One room was observed to have a large rectangular cut out in the ceiling and a white towel on the floor. Per staff, the roof was leaking and it caused mold to build on the ceiling so the facility contractor cut it out. Per staff, it is being renovated, and the hole has been there for about one week. This poses an immediate health and safety risk to the resident. Resident linen supplies are observed as in place in hallway closet. Resident bathrooms are observed. There is a full bath in the only female room. LPA observed furniture in the female resident's room as in place but not in good repair as a dresser is observed to be missing pieces and the clothing is not stored properly on the vacant bed in a pile unfolded. The shower in the female room does not have a non-skid mat in place. upon observation, it appears to be a rug or carpet in the stand up shower and the drain is beneath that carpet/rug. There is observable mold on the top of the carpet/rug in this shower. In the common bathroom, there is a bathtub/shower, it is also observed to be unclean with mold on the bathtub floor as well as on the non-skid mat. LPA also observed that the faucet handle in the common bathroom is broken. LPA is able to turn on the water but the handle spins loosely all the way around and unable to accurately test the water temperature so LPA tested the water temperature in the kitchen. Additionally, in the common bathroom, there are no paper towels present for client use.

During today's inspection visit, LPA observed a silver 4 door Mercedes in the driveway upon arriving to the facility, but later during the visit, LPA observed that it was gone. According to Edwardo, the car belongs to Janlournik Cabilogan. He says that he does not work at the facility any longer, but sleeps in the facility staff room where Edwardo resides one to two nights a week. Based on a fingerprint clearance check, LPA discovered that Janlournik has invalid fingerprints on file, therefore he should not be residing or working in the facility due to not having appropriate clearance. This poses an immediate risk to clients in care and an immediate civil is being issued in the amount of $500.

Annual inspection will be continued on a future date to review resident files, staff files, medications, client P&I monies, and additional citations related to today's inspection visit.

Citations issued on the following LIC809D page.
Civil penalty assessed for repeat violation in the amount of $1000.
Civil penalty assessed for fingerprint clearance violation in the amount of $500.
Further civil penalties may be assessed.

Report is reviewed with Edwardo Manansala and a copy is provided on this day.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Jaime Vado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 10/27/2025 03:06 PM - It Cannot Be Edited


Created By: Jaime Vado On 10/27/2025 at 01:50 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: 10/27/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/28/2025
Section Cited
CCR
80088(e)(1)

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8088(e)(1) Fixtures, Furniture, Equipment, and Supplies - (e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This regulation has not been met as evidenced by:
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Facility shall ensure water tempertaure is between 105-120 degrees faranheit and provide LPA photos/video to show that the water temperature is between regulatory requirements and a written plan of correction is to be received.
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Based on water temperature taken in the kitchen, the water temperature was measured at 124F and climbing. This poses an immediate health and safety risk to residents in care. This is a repeat violation and a civil penalty is issued in the amount of $1000.
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Type A
10/28/2025
Section Cited
CCR80019(e)

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80019(e) Criminal Record Clearance - All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility. This regulation has not been met as evidenced by:
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Facility shell develop a written plan to address how the facility will abide by this regulation at all times and in the future. Written plan shall be received by the due date assigned.
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Based on interview conducted, and fingerprint clearance check, a male adult that did not receive a criminal record clearance prior to residing, working, or volunteering at the facility was found to be on facility property. This poses an immediate health and safety risk to residents in care. Civil penalty is issued as a result in the amount of $500. Further civil penalties may be assessed in the future.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Jaime Vado
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2025


LIC809 (FAS) - (06/04)
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