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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600872
Report Date: 01/14/2025
Date Signed: 01/14/2025 01:21:04 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/14/2025 01:21 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 HOME IIFACILITY NUMBER:
415600872
ADMINISTRATOR/
DIRECTOR:		ICK, WILHELM O.FACILITY TYPE:
740
ADDRESS:3653 PACIFIC BLVDTELEPHONE:
(650) 341-9727
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
01/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Administrator/Care Manager - Moddie AndayaTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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On 01/14/2024, 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 6 residents and 3 staff present including the administrator.

This is a single two level facility with 6 bedrooms for residents. All residents reside on the ground floor only. The upper floor is for staff. The facility is licensed for age 60 and over; All may be Non-Ambulatory residents and 1 may be bedridden. Hospice waiver granted for 3 residents. Currently there are 3 residents on hospice. LPA Vado toured the facility both inside and outside with Moddie. 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 is a freezer located in the garage and a full refrigerator and freezer in the 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 primarily. Cleaning supplies and laundry soaps are also locked in the garage. Laundry area is in the garage and both the washer and dryer are operational. Additionally the facility fire panel is located in the garage above the PPE and incontinence supplies are observed to be in place stored in the garage in boxes. 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. LPA Observed a fire pull station located at the front of 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 in the kitchen and 105F in a rear bedroom half bathroom. There are two fire extinguishers in the facility that is observed with inspection tags of 11/18/2024.

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April CowanTELEPHONE: (650) 266-8865
Jaime VadoTELEPHONE: (559) 476-9353
DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2025
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 2
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 II
FACILITY NUMBER: 415600872
VISIT DATE: 01/14/2025
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LPA observed resident linen supplies and incidentals also store in a hallway closet. All resident bedrooms contain a half bath for resident use. There is one common shower room with toilet as well. 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 01/09/2025 per records reviewed. Administrator certificates are observed to be current an posted in the facility. Required signs are posted in the facility.

The following updated forms were received in person on this day:

• 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

There are no citations issued during today's inspection visit. Report is reviewed with Moddie and a copy is provided.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
LIC809 (FAS) - (06/04)
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