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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601081
Report Date: 05/03/2024
Date Signed: 05/03/2024 06:54:47 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 05/03/2024 06:54 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 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:
05/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:30 PM
MET WITH:Melody Corpuz, Moddie Andaya, Raffy JisonTIME VISIT/
INSPECTION COMPLETED:
07:00 PM
NARRATIVE
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LPA Audrey Jeung toured facility and grounds. There are 6 private client rooms--2 of which have private bathrooms--a staff room, 2 common bathrooms, living/dining area, kitchen, and 2-car garage, where the washer and dryer are located. There is a daybed in the garage which is used by staff on breaks. No accessible bodies of water or fire safety hazards observed. PPE supply is adequate. Toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Toilet and bathing facilities are equipped with grab bars and nonskid flooring material. Soap and paper towels--or cloth towels in private bathrooms--are available at all sinks. First-aid kit is inspected and complete. A Disaster and Mass Casualty Plan is posted. There are 6 residents present, and 3 staff. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, as well as staff records. Moddie Andaya and Billy Ick (x 3/24 ) are certified RCFE administrators that oversee facility operations.
Client records, including medications are reviewed.

The following updated forms are requested to be submitted to CCLD BY 5/17/24:

• LIC 308 Designation of Administrative Responsibility
• LIC 500 Personnel Report (including specific hours when administrators are present in facility)
• LIC 309 Administrative Organization

Proof of current liability insurance is given to LPA today.


Deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed and cited on a following page. See also Advisory Notes--4 pages.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2024
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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Document Has Been Signed on 05/03/2024 06:54 PM - It Cannot Be Edited


Created By: Audrey Jeung On 05/03/2024 at 05:54 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: PACIFIC CARE HOME V
FACILITY NUMBER: 415601081

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/03/2024
Section Cited
CCR
87465(h)(2)

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INCIDENTAL MEDICAL CARE
Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met, as hall cabinet where medications are
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Medications cabinet was locked and Miralax and Clearlax were secured in medications cabinet in LPA's presence.
Deficiency corrected and cleared.
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secured is unlocked upon LPA's arrival. Also, Clearlas for client 2 & Miralax for client 5 are stored in unlocked kitchen cabinet.
Licensee failed to ensure that medications are inaccessible to clients, which poses an immediate health and safety risk to clients in care.
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Type A
05/03/2024
Section Cited
CCR87355(e)(2)

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CRIMINAL BACKGROUND CLEARANCE
All individuals subject to a criminal record review pursuant to HSC 1569.17(b) shall prior to working, residing or volunteering in a licensed facility, request a transfer of a criminal record clearance as specified in Section 87355(c).
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Request to transfer criminal record clearance for staff #1 and photo ID are given to LPA for processing.
Deficiency corrected and cleared
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This requirement was not met, as staff #1 does not have criminal record clearance associated to this facility. Licensee failed to ensure that all staff have criminal record clearance associated to facility, which poses an immediate health and safety risk to clients in care.
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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 Smith
LICENSING EVALUATOR NAME:Audrey Jeung
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/03/2024 06:54 PM - It Cannot Be Edited


Created By: Audrey Jeung On 05/03/2024 at 06:13 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: PACIFIC CARE HOME V
FACILITY NUMBER: 415601081

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/17/2024
Section Cited
CCR
87411(c)(1)

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PERSONNEL REQUIREMENTS
Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
This requirement was not met, as staff #1 and #2 do not have current first aid training. Licensee failed to ensure that caregivers have
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Proof of current first aid training for S1 and S2 will be sent to CCLD BY DUE DATE
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current first-aid training, which poses a potential health, safety, or personal rights risk to clients in care.
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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 Smith
LICENSING EVALUATOR NAME:Audrey Jeung
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2024


LIC809 (FAS) - (06/04)
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