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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201951
Report Date: 07/25/2022
Date Signed: 07/25/2022 03:42:20 PM


Document Has Been Signed on 07/25/2022 03:42 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:PENDAR'S RESIDENTIAL CAREFACILITY NUMBER:
435201951
ADMINISTRATOR:MILA VALISTOFACILITY TYPE:
740
ADDRESS:515 TUSCARORA DR.TELEPHONE:
(408) 784-3669
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY:6CENSUS: 6DATE:
07/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Mila ValistoTIME COMPLETED:
03:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual inspection focusing on infection control. LPA met with Administrator (ADM), Mila Valisto.

LPA toured the facility inside and outside to include the kitchen, resident rooms, bathroom, living room, and backyard. Medication were observed in a locked cabinet. Facility has a central entry point for sign-in. LPA advised to create a symptom screening questionnaire for all visitors and staff. Hand sanitizer made available. Bathroom observed to have hygiene products, paper supplies, a lidded trash can, and hand washing sign. Facility staff clean and disinfect multiple times daily and as needed. LPA observed facility's Personal Protective Equipment (PPE) supplies. LPA advised to maintain at least a 30 day supply of all PPE. ADM states all staff are N95 fit tested. Staff has not completed recent training for Infection Control. LPA advised to provide all staff with infection control training. Facility staff not observed to be wearing a face mask. LPA informed staff of the required mask for staff and visitors. The following posters were observed to include symptoms of COVID-19.

At 2:00 p.m., LPA observed the facility's hand rails in the backyard to be in disrepair with sharp/broken pieces of wood.

Facility has not submitted their infection control plan. LPA advised to review PIN 22-13-ASC and to submit the infection control plan to the Department.

LPA will provided ADM with COVID-19 resources. The following documents were requested: LIC500, LIC610E and updated Administrator Certificate.

A deficiency was cited per California Code of Regulations, Title 22. Advisory notes provided. This report was reviewed with Administrator, Mila Valisto and the report and appeal rights was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2022
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 8


Document Has Been Signed on 07/25/2022 03:42 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131


FACILITY NAME: PENDAR'S RESIDENTIAL CARE
FACILITY NUMBER: 435201951

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87706(H)(1)

(H) Physical environment, including environmental factors that ensure a safe, secure, familiar and consistent environment for residents with dementia. 1. Environmental factors that may be considered include:... architectural and safety features (e.g., wide hallways, handrails, delayed egress, secured perimeters);...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the facility's exterior handrails was observed to be in disrepair with broken/sharp pieces of wood which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/01/2022
Plan of Correction
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Licensee will repair the exterior handrails. Licensee will send LPA a photograph of the repaired handrails via email 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: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2022
LIC809 (FAS) - (06/04)
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