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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600099
Report Date: 10/28/2025
Date Signed: 10/28/2025 01:54:52 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/28/2025 01:54 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:
10/28/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Staff - Edwardo ManansalaTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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On 10/28/2025, Licensing Program Analyst (LPA) Vado Jaime Vado conducted an unannounced case management - annual continuation inspection visit to continue the inspection from 10/27/2025. 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.

During today's inspection visit, LPA reviewed client files, staff files, medications, and client P&I monies. All are observed to be current and in place. Last disaster drill was conducted on 10/17/2025. Administrator certificate is current expiring 12/04/2026

On the 10/27/2025 annual inspection, LPA discovered citations regarding the following that is being cited today.

Buildings and Grounds - Emergency exit is blocked in the backyard by old furniture, 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. In the garage there are multiple refrigerators in place that do not work. LPA observed a client room to have a large rectangular cut out in the ceiling and a white towel on the floor due to a leaking roof. It is not covered. The hole has been left open for several days with no covering applied in between gaps of being repaired. Another client room is observed to have a broken dresser with missing drawer. LPA also confirmed that the facility does not have an operational oven. All the cooking is done via stove top and by microwave. LPA observed mold in the bathtub floor, and non-skid mat, in the common bathroom and in the private bathroom of a client's private shower on the mat both needing to be replaced. This poses an immediate health and safety risk to residents in care.

Continued on next page...
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Jaime Vado
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2025
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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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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Document Has Been Signed on 10/28/2025 01:54 PM - It Cannot Be Edited


Created By: Jaime Vado On 10/28/2025 at 08:46 AM
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: 10/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/29/2025
Section Cited
CCR
80087(c)

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Buildings and Grounds 80087(c) - All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction. 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 adressing the revoval of items stated. Written plan shall be received by the due date assigned.
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Based on observations made, LPA observed that the emergency exit is blocked in the backyard by old furniture, 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. This poses an immediate health and safety risk to residents in care.
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Type A
10/29/2025
Section Cited
CCR880076(a)(7)

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80076(a)(7) Food Services - Commercial foods shall be approved by appropriate federal, state and local authorities. All foods shall be selected, transported, stored, prepared and served so as to be free from contamination and spoilage and shall be fit for human consumption. Food in damaged containers shall not be accepted, used or retained. 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 observations made, 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. This poses an immediate health and safety risk to residents in care.
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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: 10/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/28/2025 01:54 PM - It Cannot Be Edited


Created By: Jaime Vado On 10/28/2025 at 09:27 AM
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: 10/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/29/2025
Section Cited
CCR
80072(a)(2)

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80072(a)(2) Personal Rights - To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. 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 including the method in which the rodents will be addressed such as pest control or other preventative measures. Written plan shall be received by the due date assigned.
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Based on observations made, rodent droppings are observed on the counter where the sink is located. Droppings are also observed on the kitchen floors along the walls and floors and on some areas where food is stored. LPA observed a hole on the bottom of the wall in the kitchen, behind food storage bins, where the rodents enter and exit the kitchen. This poses an immediate health risk and does not accord healthful accomodations to meet client needs.
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Type A
10/29/2025
Section Cited
CCR80087(a)

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80087(a)Buildings and Grounds -The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. 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, addressing bathroom mold, repairs to ceiling or covering, broken dresser, facility oven, and the multple non-functioning refrigerators. Written plan shall be received by the due date assigned.
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Based on observations made, LPA observed a client room to have a large rectangular cut out in the ceiling and a white towel on the floor due to leaking roof. It is not covered. The hole has been left open for several days with no covering applied in between gaps of being repaired. Another client room is observed to have a broken dresser with missing drawer. LPA also confirmed that the facility does not have an operational oven. All the cooking is done via stove top and by microwave. observed mold in the bathtub floor in the common bathroom and in the private bathroom of a client's shower. In the garage there are multiple refrigerators in place that are non-functional.This is poses an immediate health risk.
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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: 10/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
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: 10/28/2025
NARRATIVE
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Page 2

Food Services - 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. This poses an immediate health and safety risk to residents in care.

Personal Rights - Rodent droppings are observed 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. LPA observed a hole on the bottom of the wall in the kitchen, behind food storage bins, where the rodents enter and exit the kitchen. Pest control or other interventions are advised. This poses an immediate health and safety risk to residents in care.

The following documents are being requested by 11/04/2025:

- Updated LIC500
- Updated LIC308
- Copy of current administrator certificate
- Copy of current surety bond

Citations are issued on the following LIC809D pages.

Report is discussed with staff person Edwardo Manansala.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Jaime Vado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025
LIC809 (FAS) - (06/04)
Page: 5 of 5