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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600158
Report Date: 03/03/2026
Date Signed: 03/03/2026 12:37:05 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 03/03/2026 12:37 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:OUR HOUSEFACILITY NUMBER:
415600158
ADMINISTRATOR/
DIRECTOR:		PAGADOR, LIONELFACILITY TYPE:
740
ADDRESS:1916 SHOREVIEW AVENUETELEPHONE:
(650) 401-7175
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY: 6CENSUS: 5DATE:
03/03/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Ludiben Balico, Ursula & Lionel PagadorTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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LPA Audrey Jeung toured facility and grounds,which is level and fenced. There is a detached storage shed, which is used by administrator and locked. There are 3 shared client bedrooms, and 2 staff rooms--1 room has 1 bed for 2 persons and the other has 3 beds for one staff. There are no accessible bodies of water or fire safety hazards observed. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Toilet and bathing facilities are equipped with grab bars and nonskid flooring material. Hot water temperature is tested at 118 degrees in clients' bathroom. Food supply and first-aid kit are inspected and complete. Client files are reviewed, including Centrally Stored Medications Records--provided by pharmacy--and records of cash resources for 2 clients. A Disaster and Mass Casualty Plan is posted.

Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, as well as staff records and training. RCFE administrators, Lionel Pagador (x 12/27) and Lionel Pagador Jr.(x 10/27) oversee facility operations.

Proof of current liability insurance and Emergency Disaster Plan (LIC610D) are given to LPA today.

The following information/forms are requested to be sent to CCLD BY 3/17/26:
- Designation of Facility Responsibility (LIC308)
- Personnel Report (LIC500)
- Affidavit Regarding Client Cash Resources (LIC400)

Deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed and cited on following page..
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Audrey Jeung
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2026
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 03/03/2026 12:37 PM - It Cannot Be Edited


Created By: Audrey Jeung On 03/03/2026 at 11:57 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: OUR HOUSE
FACILITY NUMBER: 415600158

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/03/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/17/2026
Section Cited
CCR
87411(c)(1)

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PERSONNEL REQUIREMENTS GENERAL
Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
This requirement is not met, as all staff have expired first-aid training. Licensee failed to ensure that staff providing care maintain
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Proof of current first aid training for ALL staff will be sent to CCLD BY DUE DATE
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valid first-aid training, which poses a potential health and safety risk to clients in care.
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Type B
03/17/2026
Section Cited
HSC1569.696

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HEALTH AND SAFETY CODE
RCFEs shall provide training to direct care staff on postural supports, restricted conditions or health services, hospice care...training shall include...4 hours of training on the care, supervision, and special needs of those residents...
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Proof of postural supports, restricted health conditons and hospice care training for staff #2, #4 and #5 will be sent to CCLD BY DUE DATE
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Four hours of training thereafter of in-service training per year on the subject of serving those residents. This requirement is not met, as there is no proof of this annual training for staff #2, #4 and #5. Licensee failed to ensure that all direct care providers have this annual training, which poses a potential health, safety or personal rights 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:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2026


LIC809 (FAS) - (06/04)
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