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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601081
Report Date: 04/10/2025
Date Signed: 04/10/2025 03:18:57 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 04/10/2025 03:18 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 VFACILITY NUMBER:
415601081
ADMINISTRATOR/
DIRECTOR:		ANDAYA, MODDIEFACILITY TYPE:
740
ADDRESS:1790 BROOKS STTELEPHONE:
(650) 315-2152
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY: 6CENSUS: 6DATE:
04/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administrator - Moddie AndayaTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On 04/10/2025, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced required 1 year inspection. LPA met with co-administrator Moddie Andaya and explained the purpose of today's visit. Currently there are 6 residents in place and 3 staff in place, one of which is the administrator.

The facility is licensed for age range 60 and over. All may be non-ambulatory, of which one may be bedridden. Hospice waiver approved for 2. Bedroom 5 is approved for bedridden. There currently are no hospice and no bedridden residents according to staff. This is a single level facility. Facility temperature is comfortable for residents in care. Facility emergency food supplies such as canned goods are in a large storage closet located in the garage. Additional supplies are in the garage as well. There are 6 resident rooms. Water temperature is tested in the common full bath where residents shower. It was measured at 106F. Water temperature was also tested in room #3 at 106F as well. Cleaning supplies in the kitchen are observed as locked beneath the kitchen sink. Additional cleaning supplies are locked in the garage in a large storage cabinet. Facility knives are observed to be locked in a drawer across from the stove/cooking range. Kitchen food supplies are observed to be in place with 2 day fresh food supply and canned goods fulfilling the 7 day emergency food supply. A tour of the outside of the facility is conducted. Emergency routes are free and clear of any obstructions. Smoke detectors and carbon monoxide detectors are located through out the facility. The facility is also equipped with 2 fire alarm pull stations, one in the front, and one in the back of the facility. LPA observed 2 fire extinguishers in the facility with inspection tags dated 03/20/2025. Facility conducts emergency drill quarterly. The last drill that was conducted is logged with a date of 02/19/2025. Linens are in place for resident use stored in a hallway closet and in resident rooms.

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NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Jaime Vado
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/10/2025
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 V
FACILITY NUMBER: 415601081
VISIT DATE: 04/10/2025
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LPA observed all resident rooms and observed that they contain the required furniture and lighting as outlined in Title 22. Medications, medical kit, are stored in locked medication closet in the main hallway. Toilet and bathing facilities are equipped with grab bars and nonskid flooring material. Hygiene supplies are in place. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed as current. LPA reviewed staff and resident files on this day which appear to be current based on review. Staff training records are observed to be current and in place. Administrator certificate for Moddie Andaya is observed as current expiring 11/15/2025.

Report is reviewed with Moddie Andaya. A copy of this report is provided to the facility.

No citations issued.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Jaime Vado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
LIC809 (FAS) - (06/04)
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