415601076-5-12-2025-14-AS-MHAN-DGLQTQ-20250512122731

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415601076
Report Date: 05/12/2025
Date Signed: 05/12/2025 03:20:33 PM

Document Has Been Signed on 05/12/2025 03:20 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:	PACALDO LLC		FACILITY NUMBER:	415601076
ADMINISTRATOR/ DIRECTOR:	MADRIGAL, OSCAR		FACILITY TYPE:	740
ADDRESS:	1450 GREENWOOD WAY		TELEPHONE:	(650) 952-6641
CITY:	SAN BRUNO	STATE: CA	ZIP CODE:	94066
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 2	DATE:	05/12/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:15 AM
MET WITH:	Administrator, Oscar Madrigal		TIME VISIT/ INSPECTION COMPLETED:	12:40 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	On May 12, 2025 Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. LPA met with caregivers, Genalyn Napo and Elizabeth Macabales Esguerra and explained the purpose of the visit. The administrator, Oscar Madrigal and Licensee, Juliet Pacaldo arrived shortly thereafter and assisted with the inspection. LPA toured the facility inside out and inspected the living room, dining area, kitchen, bedrooms, bathrooms, and backyard. The indoor and outdoor passageways were free of obstruction. The facility has 6 private rooms. Furniture and furnishings were observed to be sufficient. Food supplies were sufficient of 2- days perishables and 7- days of non-perishables. Toilet, hand washing and bathing areas were observed clean and in operating condition. Facility exits are equipped with audible alarms. Comfortable temperature is maintained and lighting is sufficient for comfort Bed sheets, linens, and towels were observed to be sufficient and able to meet the needs of the residents at this time. Central storage for medications, and chemicals were observed to be locked and inaccessible to residents in care; LPA observed sharps were stored in the kitchen on the dish rack not locked and accessible to residents in care. Hot water temperature in the kitchen and bathroom were measured at 108-110 degrees Fahrenheit. Fire extinguishers were checked and last inspected on 1/21/2025 A review of (2) resident files was conducted and noted on the LIC 858. A review of (2) staff files was conducted and noted on the LIC 859. Civil penalty of $200 dollars is being assessed today as S1 and S2 were not associated with the facility. Based on observation, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. . This report is reviewed and discussed with administrator. A copy of this report and the appeal rights were provided.

April Cowan	TELEPHONE: (650) 266-8889
Murial Han	TELEPHONE: (619) 209-9761
	DATE: 05/12/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2025

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: PACALDO LLC	FACILITY NUMBER: 415601076
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87309(a)

Storage Space and Access

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed sharps stored in the kitchen dish rack are locked and accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/13/2025
	Plan of Correction
1 2 3 4	The administrator/licensee will develop a plan to ensure compliance and will provide a copy of the plan of correction to CCL by 5/13/2025.

Type A

Section Cited

CCR

87355(e)(3)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as S1 and S2 are transferred from the sister facility, however, the criminal records were not transferred to this facility which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/13/2025
	Plan of Correction
1 2 3 4	The administrator/licensee will develop a plan to ensure compliance and will provide a copy of the plan of correction to CCL by 5/13/2025. A civil penalty of $200 is being assessed today.

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	TELEPHONE: (650) 266-8889
Murial Han	TELEPHONE: (619) 209-9761
	DATE: 05/12/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2025

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: PACALDO LLC	FACILITY NUMBER: 415601076
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as S2 did not have required training records in the personnel file which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/13/2025
	Plan of Correction
1 2 3 4	The administrator/licensee will develop a plan to ensure compliance and will provide a copy of the plan of correction to CCL by 5/13/2024.

Type A

Section Cited

CCR

87506(a)

Resident Records

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as the facility did not have complete, and current record for R2 which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/13/2025
	Plan of Correction
1 2 3 4	The administrator/licensee will develop a plan to ensure compliance and will provide a copy of the plan of correction to CCL by 5/13/2024.

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	TELEPHONE: (650) 266-8889
Murial Han	TELEPHONE: (619) 209-9761
	DATE: 05/12/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2025

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: PACALDO LLC	FACILITY NUMBER: 415601076
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87506(b)(15)

Resident Records

(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above the facility did not have an admission agreement for R1 and R2 completed during the inspection which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/13/2025
	Plan of Correction
1 2 3 4	The administrator/licensee will develop a plan to ensure compliance and will provide a copy of the plan of correction to CCL by 5/13/2024.

Type A

Section Cited

CCR

87456(a)(2)

Evaluation of Suitability for Admission

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as R1's pre-admission evaluation was incomplete as it was not signed by the resident and/or the responsible party; R2 was admitted on 5/12/2025 without a pre-admission evaluation which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/13/2025
	Plan of Correction
1 2 3 4	The administrator/licensee will develop a plan to ensure compliance and will provide a copy of the plan of correction to CCL by 5/13/2024.

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	TELEPHONE: (650) 266-8889
Murial Han	TELEPHONE: (619) 209-9761
	DATE: 05/12/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2025

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: PACALDO LLC	FACILITY NUMBER: 415601076
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87458(a)

Medical Assessment

(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as R2 was admitted on 5/11/2025 and there was no medical assessment in the file which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/13/2025
	Plan of Correction
1 2 3 4	The administrator/licensee will develop a plan to ensure compliance and will provide a copy of the plan to CCL by 5/13/2025.

Type A

Section Cited

CCR

87458(c)(1)(A)

Medical Assessment

(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as R2 was admitted on 5/12/2025 and there is no communicable TB status in the file which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/13/2025
	Plan of Correction
1 2 3 4	The administrator/licensee will develop a plan to ensure compliance and will provide a copy of the plan to CCL by 5/13/2025.

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	TELEPHONE: (650) 266-8889
Murial Han	TELEPHONE: (619) 209-9761
	DATE: 05/12/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2025

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: PACALDO LLC	FACILITY NUMBER: 415601076
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

HSC

1569.695(c)

Other Provisions

(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 not required 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 requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above LPA observed the facility was not able to provide any documentation to ensure drills were completed accordingly which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/13/2025
	Plan of Correction
1 2 3 4	The administrator/licensee will develop a plan to ensure compliance and will provide a copy of the plan to CCL by 5/13/2025.

Type A

Section Cited

CCR

87608(a)(3)

Postural Supports

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as R1 and R2 have bedrails without a written order which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/13/2025
	Plan of Correction
1 2 3 4	The administrator/licensee will develop a plan to ensure compliance and will provide a copy of the plan to CCL by 5/13/2025.

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	TELEPHONE: (650) 266-8889
Murial Han	TELEPHONE: (619) 209-9761
	DATE: 05/12/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2025

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: PACALDO LLC	FACILITY NUMBER: 415601076
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87411(F)

This requirement is not met as evidenced by: Personnel Requirements- General (f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test,
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed there is no TB/chest X-ray status in S1's file which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/13/2025
	Plan of Correction
1 2 3 4	The administrator will develop a plan of correction to ensure compliance and will provide a copy of the plan of correction to CCL by 5/12/2025.

Type A

Section Cited

CCR

87405(d)(1)(2)(3)

Administrator - Qualification and Duties This requirement is not met as evidenced by: (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (1) Knowledge of the requirements for providing care and supervision appropriate to the residents. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. (3) Ability to maintain or supervise the maintenance of financial and other records.
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as the administrator did not ensure all the required documents are completed prior to R2 admission, all the required documents are completed for S1 and S2's personnel files, and the files are available at the facility for inspection which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/13/2025
	Plan of Correction
1 2 3 4	The administrator will review this regulation and provide proof after the review. In addition, the administrator will provide a plan of correction to ensure compliance and will provide a copy of the plan of correction to CCL by 5/13/2025.

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	TELEPHONE: (650) 266-8889
Murial Han	TELEPHONE: (619) 209-9761
	DATE: 05/12/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2025

LIC809 (FAS) - (06/04)

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