<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210013
Report Date: 09/09/2025
Date Signed: 09/09/2025 11:35:46 AM

Document Has Been Signed on 09/09/2025 11:35 AM - 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:PARTNERS FOR INDEPENDENCE- INCLUSION CTR.FACILITY NUMBER:
419210013
ADMINISTRATOR/
DIRECTOR:		EMMANUEL CANONFACILITY TYPE:
775
ADDRESS:1608 GILBRETH ROADTELEPHONE:
(650) 259-8065
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY: 60CENSUS: 33DATE:
09/09/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Program Director, Renz CorralesTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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 September 9, 2025, Licensing Program Analyst (LPA) Murial Han conducted an unannounced Case Management visit to deliver the investigation findings of an incident that was reported by the facility. LPA met with the Program Director, Renz Corrales and explained the purpose of the visit.

On 8/18/2025, the facility reported to CCL that on 8/15/2025, at 10:30 AM during the community outing, resident #1 (R1) and resident #2 (R2) were in the van by themselves as staff members were assisting and supervising the other residents in the park. R1 who was sitting in the back of the van attacked R2 who was sitting in the passenger seat and grabbed his/her left leg and started masturbating.

As part of the investigation, LPA interviewed the Program Director, facility staff members and reviewed documents.

According to the Program Director and staff members, R1 has been at the facility for many years and R1 has had episodes of grabbing male feet, and start to masturbate. In addition, the Program Director stated that on the day of the incident, R1 was provided with one to one care and supervision with staff #1 (S1) to ensure the safety of all the residents.

According to S1, on the day of the incident, R1 did not want to leave the van which happened often so S1 decided to assist the other residents with getting them off the van and helping them at the picnic table in the park while the driver (S2) was parking the van resulting in R1 and R2 in the van without any supervision.

NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Murial Han
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
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)
Page: 2 of 4
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: PARTNERS FOR INDEPENDENCE- INCLUSION CTR.
FACILITY NUMBER: 419210013
VISIT DATE: 09/09/2025
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
26
27
28
29
30
31
32
According to S2, after the van was parked, he/she went to assist the residents at the picnic table with their snacks and one of the residents did not have a spoon so he/she went back to the van to get a spoon and saw R1 who was on the floor, grabbing R2's foot and masturbating.

Based on R1's Individual Service Plan Annual Meeting From September 2024 through August 2025, it indicating that R1 needs a staff who will keep a close eye on R1 and it also indicated that staff shall always know where R1's whereabout and when R1 might approach another individual.

According to R2's hospital record, R2 sustained a Left Fibular Fracture and the reason for the visit was Leg Pain - Swelling.

Based on interviews, observations and record reviews, this incident has been substantiated as the facility was aware of R1's behavior and to ensure the safety of R1 and the other residents, the facility assigned S1 to R1 to provide one to one care and supervision, However, S1 decided to assist other residents in the park while R1 and R2 were left unattended in the van by themselves resulting the attack where R2 sustained a Left Fibular Fracture.



Based on observation, interviews, and record review, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in additional civil penalties.

AN IMMEDIATE CIVIL PENALTY OF $500 WAS ASSESSED TODAY FOR LACK OF CARE AND SUPERVISION.

THE PROGRAM DIRECTOR WAS INFORMED THAT AN ADDITIONAL CIVIL PENALTY IS STILL BEING DETERMINED AND MIGHT BE ASSESSED BASED ON HEALTH AND SAFETY CODE ยง1569.49.

This report is reviewed and discussed with the Program Director.

A copy of this report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Murial Han
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 09/09/2025 11:35 AM - It Cannot Be Edited


Created By: Murial Han On 09/09/2025 at 10:43 AM
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: PARTNERS FOR INDEPENDENCE- INCLUSION CTR.
FACILITY NUMBER: 419210013

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/10/2025
Section Cited
CCR
82078(a)

1
2
3
4
5
6
7
82078 Responsibility for Providing Care and Supervision(a) The licensee shall provide care and supervision necessary to meet the client's needs... this requirement is not met as evidenced by
1
2
3
4
5
6
7
The Licensee /administrator will develop a plan of correction to ensure R1 is being cared and supervised at all times. The plan of correction shall include the actions that the facility took since the incident and the actions will be implemented moving forward to ensure the safety of R2 and all the residents.
8
9
10
11
12
13
14
Based on interviews, observation, and record review, R1 and R2 were left in the van unattended resulting in R1 attacked R2, grabbed his/her left foot and started to masturbate which resulted R2 sustained a Left Fibular Fracture which poses an immediately health and safety risk to residents in care
8
9
10
11
12
13
14
The plan shall include staff training. The Licensee/administrator will submit a copy of the plan to CCL by 9/10/2025.

AN IMMEDIATE CIVIL PENALTY OF $500 WAS ASSESSED TODAY FOR LACK OF CARE AND SUPERVISION.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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
NAME OF LICENSING PROGRAM MANAGER:
Murial Han
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2025


LIC809 (FAS) - (06/04)
Page: 4 of 4