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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210013
Report Date: 10/15/2025
Date Signed: 10/15/2025 02:15:07 PM

Document Has Been Signed on 10/15/2025 02:15 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:PARTNERS FOR INDEPENDENCE- INCLUSION CTR.FACILITY NUMBER:
419210013
ADMINISTRATOR/
DIRECTOR:		RENZ CORRALESFACILITY TYPE:
775
ADDRESS:1608 GILBRETH ROADTELEPHONE:
(650) 259-8065
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY: 60CENSUS: 34DATE:
10/15/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Administrator, Renz CorralesTIME VISIT/
INSPECTION COMPLETED:
02:20 PM
NARRATIVE
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On 10/15/2025, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to follow up on an incident that was reported by the facility. LPA met with Licensees, Adam Canon and Matthew Haake- Canon and administrator, Renz Corrales and LPA explained the purpose of the visit.

On 10/14/2025, facility reported that resident #1 (R1) slapped staff #1 (S1) resulting in S1 pushing R1 against the wall and placed his/her hand on R1's neck. This incident was witnessed by Staff #2 (S2) and Staff #3 (S3). After the incident, S1 was sent home and placed on administrative leave. After the incident, R1 was assessed and there was no injuries noted. The facility reported it to the local police department, R1's responsible party, GGRC and R1's residence.

During today's visit, LPA interviewed R1 who remembered partially of the incident but was not able to verbalize the details due to R1's diagnosis. R1 physically demonstrated a slap motion with his/her hand but was not able to provide additional details.

During today's visit, LPA interviewed S2 and S3 and both of them reported that the incident happened in the conference room.

S2 stated that he/she did not see R1 slapped S1 as he/she was entering the conference room but witnessed S1 pinned R1 against the wall and his/her hand was on R1's neck. Subsequently, S1 told S2 that R1 had slapped him/her.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Murial Han
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2025
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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Document Has Been Signed on 10/15/2025 02:15 PM - It Cannot Be Edited


Created By: Murial Han On 10/15/2025 at 01:05 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: PARTNERS FOR INDEPENDENCE- INCLUSION CTR.
FACILITY NUMBER: 419210013

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/16/2025
Section Cited
CCR
82072(a)(3)

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82072 Personal Rights (a) Each client shall have personal rights which include, but are not limited to, the following: (3) To be free from corporal or unusual punishment, infliction of pain,...This requirement is not met as evidenced by:
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The Licensee shall develop a plan of correction to ensure all residents are free from corporal or unusual punishment and the plan shall include staff training. The licensee will provide a copy of the plan to CCL
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Based on observation, interview and record review, S1 pinned and placed his/her hand on R1's neck as R1 was having a behavior episode at the facility which poses an immediate health and safety risk to resident in care.
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by 10/16/2025.

An Immediate $500 is being assessed today.

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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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Murial Han
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2025


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: PARTNERS FOR INDEPENDENCE- INCLUSION CTR.
FACILITY NUMBER: 419210013
VISIT DATE: 10/15/2025
NARRATIVE
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LPA interviewed S3 who stated that he/she was in the conference room with another resident when the incident happened. S3 stated that R1 slapped S1 in which resulted S1 pushed R1 against the wall and placed his/her hand on R1's neck.

Based on interviews, observation, and records review, this incident is substantiated as S1 pinned and placed his/her hand on R1's neck who was having a behavior episode at the facility. 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 THE VIOLATION OF PERSONAL RIGHTS.

This report is reviewed and discussed with the administrator and the licensees and a copy is provided.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Murial Han
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025
LIC809 (FAS) - (06/04)
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