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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600872
Report Date: 12/29/2025
Date Signed: 12/29/2025 02:08:04 PM

Document Has Been Signed on 12/29/2025 02:08 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: 6CENSUS: 6DATE:
12/29/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Administrator/Care Manager - Moddie AndayaTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On 12/29/2025, 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 a pantry located in the formal dining area. 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. Laundry area is in the garage and both the washer and dryer are operational.

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NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Jaime Vado
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/29/2025
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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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: 12/29/2025
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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 112F in the kitchen and 105F in the resident rooms. There are two fire extinguishers in the facility that is observed with inspection tags of 11/07/2025. LPA observed resident linen supplies and incidentals also store in a hallway closet. There is one common shower room located in the rear of the facility. 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 12/05/2025 per records reviewed. Administrator certificates are observed to be current an posted in the facility. Required signs are posted in the facility. Administrator certificate is current expiring on 11/15/2027.

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

• Copy of updated administrator certificate
• LIC308 Designation of responsible staff person
• LIC500 Staff Schedule


There are no citations issued during today's inspection visit. Report is reviewed with Moddie and a copy is provided.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Jaime Vado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2025
LIC809 (FAS) - (06/04)
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