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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600871
Report Date: 01/09/2025
Date Signed: 01/09/2025 02:15:08 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/09/2025 02:15 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:PACIFIC CARE HOMEFACILITY NUMBER:
415600871
ADMINISTRATOR/
DIRECTOR:		JISON, RAFAEL A.FACILITY TYPE:
740
ADDRESS:3647 PACIFIC BLVDTELEPHONE:
(650) 345-1796
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY: 6CENSUS: 5DATE:
01/09/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Administrator - Moddie Andaya TIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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On 01/09/2024, Licensing program Analyst (LPA) Jaime Vado conducted an unannounced required - 1 year inspection. LPA met with Administrator Moddie Andaya and explained the purpose of today’s visit. Currently there are 5 residents and 3 staff present including the administrator.

This is a single level facility with 6 bedrooms for residents. The facility is licensed for age 60 and over; All may be Non-Ambulatory residents; Hospice waiver granted for 3 residents. Currently there is only 1 resident on hospice. LPA Vado toured the facility both inside and outside with Maria. All outdoor and indoor passageway are free and clear of obstructions for emergency exit routes in case of fire or emergency. Facility's ambient temperature is comfortable for residents and LPA. No pools or bodies of water were observed during today's visit on the premises. LPA observed fresh food supplies and emergency one week of nonperishable and two (2) days of perishable foods as in place. There are refrigerators with freezers located in the garage and kitchen. Canned food supplies are primarily observed as stored in the garage. Knives are locked in the kitchen in a drawer next to the stove. Toxic chemicals are stored in the garage. Cleaning supplies and laundry soaps are also locked in the garage. PPE and incontinence supplies are observed to be in place in case of any use. Medications are locked in the kitchen in a large cabinet. Each resident room is observed to contain the required furniture as outlined in regulations. Facility has functioning smoke detectors and carbon monoxide detectors through out the facility. The facility is equipped with private half baths in each resident room and a common full bathroom for bathing. All are observed in good working order for resident use. Water temperature is tested at 120F. There are two fire extinguishers in the facility that is observed with inspection tags of 11/18/2024.


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SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2025
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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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: PACIFIC CARE HOME
FACILITY NUMBER: 415600871
VISIT DATE: 01/09/2025
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LPA observed resident linen supplies and incidentals also store in a hallway closet. Shower room floor is equipped with a non-skid mats when in use. Based on review of all resident files, and medications all items are current and logged accurately. Last fire/disaster drill was conducted on 02/24/2024 per records reviewed. This poses a health and safety risk to residents in care. Administrator certificates are observed to be current and posted in the facility.

The following updated forms are requested to be submitted to CCLD by 01/16/2025:

• Copy of updated administrator certificate
• Copy of facility's liability insurance
• LIC308 Designation of responsible staff person
• LIC610E Emergency Disaster Plan
• LIC500 Staff Schedule
• Copy of control of property or copy of lease

Type B citation is issued during today's inspection visit. Report is reviewed with the administrator and a copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/09/2025 02:15 PM - It Cannot Be Edited


Created By: Jaime Vado On 01/09/2025 at 01:24 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: PACIFIC CARE HOME
FACILITY NUMBER: 415600871

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/16/2025
Section Cited
HSC
1569.695(c)

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(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is notrequired during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This regulation has not been met as evidenced by:
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Facility shall write a plan of correction statement addressing how they will address this citation going forward. Statement and proof of emergency disaster drill conducted.
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Based on facility records reviewed, the facility last conducted an emergency disaster drill on 02/24/2024. This poses a 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.
SUPERVISOR'S NAME:April Cowan
LICENSING EVALUATOR NAME:Jaime Vado
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2025


LIC809 (FAS) - (06/04)
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