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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201951
Report Date: 10/13/2023
Date Signed: 10/13/2023 03:42:39 PM


Document Has Been Signed on 10/13/2023 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: 5DATE:
10/13/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Mila ValistoTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) David Marrufo and Mita Partoza conducted a Case Management visit and met with Mila Valisto. LPAs visited the facility to conduct a complaint investigation visit.

During visit, LPAs observed that resident R1's latest Physician's Report was completed on 12/05/2019. The Physician's Report stated R1 has a diagnosis of dementia. LPAs also observed resident R2 did not have a Functional Capabilities Form in R2's resident records.

LPAs observed that a plank on one of the exterior wooden hand rails was loose during visit.

An Advisory Note was issued. See LIC9102 for more information.

Deficiencies were cited as per California Code of Regulations Title 22. See LIC809-D for more information.

This report was reviewed with Administrator Mila Valisto and a copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2023
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 10/13/2023 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: 10/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/20/2023
Section Cited
CCR
87705(c)(5)

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Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and
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Licensee agrees to update R1's LIC602A Physician's Report by POC date and submit a copy of the report to licensing once completed.
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a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement was not met as evidenced by: Licensee did not ensure that resident R1 had a medical assessment that was updated annualy, which poses a potential safety risk to residents in care.
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Type B
10/20/2023
Section Cited
CCR87506(b)(17)(B)

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87506 Resident Records (b) Each resident’s record shall contain at least the following information: (17) Documents and information required by the following: (B) Section 87459, Functional Capabilities. This requirement was not met as evidenced by: Licensee did not
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Licensee agrees to complete a Functional Capabiliities form for resident R2 and submit a copy of the completed form by POC date.
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ensure that resident R2's resident record included a Functional Capabilities form, which poses a potential safety risk to residents 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: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2023
LIC809 (FAS) - (06/04)
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