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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601081
Report Date: 12/15/2023
Date Signed: 12/15/2023 03:55:06 PM


Document Has Been Signed on 12/15/2023 03:55 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:ANDAYA, MODDIEFACILITY TYPE:
740
ADDRESS:1790 BROOKS STTELEPHONE:
(650) 315-2152
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY:6CENSUS: 5DATE:
12/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Melody Corpuz, Moddie AndayaTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct an annual required inspection. LPA met with facility staff Melody Corpuz, and explained the purpose of the visit. Facility staff contacted Administrator Moddie Andaya, which stated he will arrive after completing a Christmas Party for another care home. Administrator Moddie arrived later during the visit to meet with LPA Valerio.

LPA Valerio and facility staff toured the physical plant to ensure compliance with Title 22 regulations. LPA inspected 6 resident bedrooms, 1 staff area, kitchen area, common area, 2 bathrooms, garage area, and exterior plant. Resident bedrooms were equipped with required furniture, were observed to be clean without any odors, and free from debris. The kitchen was observed to be clean and to have sharps locked away and inaccessible to residents. The facility was observed to have a minimum of 2 days of perishable food items, 7 days of non-perishable food items, and an emergency supply of food. Bathrooms were equipped with non-skid mats, toilet paper, paper hand towels, soap, and a trash can. Hot water temperature was measured between the regulatory range of 105.0*F - 120.0* degrees F. Fire extinguishers were observed to be fully charged with an annual inspection on 03/03/2023. LPA observed the exterior plant to be clean, have areas for outside visits, and to have no obstructions of emergency exits.

LPA spoke to facility staff and a resident during the visit. Staff were observed cleaning the facility, checking in on residents, and assisting with a facility visitor. Residents were observed dancing in a chair to Christmas music, watching television, and taking a nap. LPA reviewed staff files and resident files. LPA observed 2 staff files to be current with up to date training. Three (3) resident files were reviewed. 1 out of 3 resident files were observed to be incomplete.
LPA requested the following documentation be sent to the San Bruno Regional Office: LIC 309 Administrative Organization, LIC 500, LIC 308, LIC 610E, and Copy of Liability Insurance.
Per California Code of Regulations (CCR) - Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached LIC 809 - D. Appeal Rights were provided. An exit interview was held with Administrator Moddie, and a copy of the report was provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-263-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2023
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 12/15/2023 03:55 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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
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Based on records review, the licensee did not comply with the section cited above in 1 out of 3, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/15/2024
Plan of Correction
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Licensee to send copy of pre-admission appraisal and appraisal to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-263-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2023
LIC809 (FAS) - (06/04)
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