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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201951
Report Date: 05/19/2025
Date Signed: 05/19/2025 05:53:08 PM

Document Has Been Signed on 05/19/2025 05:53 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/
DIRECTOR:		MILA VALISTOFACILITY TYPE:
740
ADDRESS:515 TUSCARORA DR.TELEPHONE:
(408) 784-3669
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
05/19/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:45 PM
MET WITH:Mario LaganTIME VISIT/
INSPECTION COMPLETED:
06:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct a case management – deficiencies visit. LPA met with Designated Administrator, Mario Lagan and Licensee, Marie Pendar.

The purpose of the visit is to address Title 22 violations observed during a complaint investigation (Control Number 26-AS-20250124153302).

During the investigation, staff stated that on 01/23/2025 the only 2 staff working at the facility both left the facility to walk about 200 feet away (0.2 miles) to pick up R1, after R1 eloped from the facility. The staff instructed 1 resident to supervise 3 other residents for about 5-10 minutes while the staff went to get R1. Staff stated that the 1 resident who was asked to supervise the other resident was the most “reliable” to watch the remainder of the residents, as the resident had the most cognition.

During the investigation, it was stated that R1’s elopement behavior began in the beginning of January 2025. Based on review of R1’s appraisal/needs and services plan it was last updated in year 2023. R1’s appraisal/needs and services plan was not updated to address R1’s new elopement behavior.

During today's visit, LPA observed a pad lock device located at the bottom left side of the front entrance door. It was stated that the pad lock was installed to help reduce R1's elopement behavior. LPA observed an audible door alarm located at the top left of the front door, however, the door alarm was not working. Page 1 of 2.
Jackie JinTELEPHONE: (714) 319-3786
Christine KabaritiTELEPHONE: (408) 324-2112
DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2025
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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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
VISIT DATE: 05/19/2025
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During today's visit, staff removed the pad lock located at the bottom left side of the front door. Licensee states a plan to replace the door alarm at the front door. Licensee states to be currently working with R1's insurance company to help implement a 1:1 staff for R1.

It was also stated that on 04/25/2025, R1 eloped from the facility and was found by staff about 300 feet away from the facility. Based on review of the facility's incident reports, the facility did not report R1's elopement to the Department.

Deficiencies were cited per California Code of Regulations, Title 22. See LIC809-D.

An immediate $500 civil penalty was assessed due to absence of supervision on 01/23/2025.

This report was reviewed with Licensee, Marie Pendar and a copy of the report and appeal rights were provided.

Page 2 of 2.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine KabaritiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 05/19/2025 05:53 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: 05/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/19/2025
Section Cited
CCR
87413(a)(1)

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(a) In each facility: (1) When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks. This requirement is not met as evidenced by:
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Licensee will conduct staff training on the facility's elopement policies and procedures and ensuring proper supervision at all times. Licensee will submit training document to LPA Kabariti via email by POC due date.
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Based on interview, record review and observation the licensee did not ensure that a staff member was present with 4 residents, when 2 out of 2 staff members left to pick up R1 after R1 eloped from the facility which poses an immediate health, safety, and personal rights risk to persons in care.
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Type A
05/20/2025
Section Cited
CCR87307(d)(6)

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(d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by:
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Licensee removed the pad lock on the front door during visit. Licensee will conduct a staff training regarding ensuring exit doors are free of obstruction. Licensee will submit training document to LPA Kabariti via email by POC due date.
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Based on interview, record review, and observation the licensee did not ensure the front door was not free of obstruction as the front door contained a pad lock at the bottom left side of the front door which poses an immediate health, safety and personal rights risk to persons 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.
Jackie JinTELEPHONE: (714) 319-3786
Christine KabaritiTELEPHONE: (408) 324-2112

DATE: 05/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2025

LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 05/19/2025 05:53 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: 05/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/26/2025
Section Cited
CCR
87463(b)

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(b) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented as specified in Section 87466, Observation of the Resident. This requirement is not met as evidenced by:
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Licensee corrected the deficiency prior to visit by updating R1's appraisal/needs and services plan on 03/27/2025. LPA obtained a copy of the updated appraisal/needs and services plan.
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Based on interview, record review and observation the licensee did not ensure to update R1’s reappraisal to document R1’s new behavior of elopement which poses a potential health, safety, and personal rights risk to persons in care.
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Type B
05/26/2025
Section Cited
CCR87211(a)(1)(D)

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(a) ... : (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. … (D) Any incident which threatens the welfare, safety or health of any resident, ... or unexplained absence of any resident.
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Licensee will complete training with staff regarding reporting requirements. Licensee will submit the training document to LPA Kabariti via email by POC due date.
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Based on interview, record review and observation the licensee did not ensure to report R1's elopement incidnet on 04/25/2025 to the Department which poses a potential health, safety and personal rights risk to persons 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.
Jackie JinTELEPHONE: (714) 319-3786
Christine KabaritiTELEPHONE: (408) 324-2112

DATE: 05/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2025

LIC809 (FAS) - (06/04)
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