<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600872
Report Date: 02/20/2024
Date Signed: 02/20/2024 07:39:30 PM


Document Has Been Signed on 02/20/2024 07:39 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:PACIFIC CARE HOME IIFACILITY NUMBER:
415600872
ADMINISTRATOR:ICK, WILHELM O.FACILITY TYPE:
740
ADDRESS:3653 PACIFIC BLVDTELEPHONE:
(650) 341-9727
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY:6CENSUS: 6DATE:
02/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Moddie Andaya and Wilhelm IckTIME COMPLETED:
07:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
LPA Audrey Jeung toured facility and grounds. Six residents are accommodated in private rooms--5 have private half bathrooms--all of which have direct exits to outside. There is a staff room with 5 beds, as well as upstairs staff residence that includes one bedroom. Fenced backyard is level, landscaped, and partially paved; it is shared with Pacific Care Home (3647 Pacific Blvd.)--also operated by J & I LLC. There are no accessible bodies of water or fire safety hazards observed. Carbon monoxide detector is tested and operable. Medications and sharps are stored appropriately and inaccessible to clients, a comfortable room temperature is maintained, and lighting is sufficient for safety. First-aid kit is complete and maintained. Client files are reviewed, and medications are recorded on Centrally Stored Medications Records. 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 training records.
Wilhelm Ick (x 3/24) and Moddie Andaya are certified RCFE administrators that oversee facility operations, with assistance from Rafael Jison (RCFE x 3/24).
As per legislation, effective 1/1/2015, the following information is posted: 1) text of Health and Safety Code 1569.269 AND CCR Title 22 Section 87468 (Personal Rights form LIC613C), per AB2171; 2) CCLD Hotline information, per SB895.

Signature page of Emergency Disaster Plan(LIC610-E) & proof of current liability insurance are given to LPA.
The following licensing forms are requested to be updated and submitted to CCLD by 3/5/24:

- Personnel Report (LIC500)
- Administrative Organization (LIC309)
- Designation of Facility Responsibility (LIC308)

Deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed and cited on following pages.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2024
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


Document Has Been Signed on 02/20/2024 07:39 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: PACIFIC CARE HOME II
FACILITY NUMBER: 415600872

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87606(c)
Care of Bedridden Residents
(c) To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on client records review, the licensee did not comply with the section cited above, as 2 residents are bedridden, per MD reports, but facility is approved for just one bedridden resident.
This which poses an immediate health, safety or personal rights risk to persons in care.
Clients #1 and #5 are bedridden, and both are on hospice care
POC Due Date: 02/21/2024
Plan of Correction
1
2
3
4
Plan of correction to be submitted to CCLD BY DUE DATE
Type A
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above, as full bed rail is used by client #3, who is not receiving hospice care. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/20/2024
Plan of Correction
1
2
3
4
Full bed rail was shortened and relocated to head of bed in LPA's presence. Deficiency corrected and cleared.
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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 02/20/2024 07:39 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: PACIFIC CARE HOME II
FACILITY NUMBER: 415600872

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.696(a)
Other Provisions
(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on staff training records review, the licensee did not comply with the section cited above, as there is no evidence of required 4 hours of training on postural supports and restricted health conditions for all staff.
This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/05/2024
Plan of Correction
1
2
3
4
Proof of required 4 hours of training on postural supports, restricted health conditions and hospice care for all staff will be sent to CCLD BY DUE DATE.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 02/20/2024 07:39 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: PACIFIC CARE HOME II
FACILITY NUMBER: 415600872

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)3)
MAINTENANCE AND OPERATION
Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above, as hot water temperature tested at 132 degrees in 2 bathroom sinks, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/21/2024
Plan of Correction
1
2
3
4
Hot water temperature shall be lowered and maintained within range of 105 and 120 degrees.
Proof of correction to be sent to CCLD BY DUE DATE
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4