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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201951
Report Date: 07/24/2025
Date Signed: 07/24/2025 05:50:24 PM

Document Has Been Signed on 07/24/2025 05:50 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: 6CENSUS: 5DATE:
07/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Mario Lagan Designated AdministratorTIME VISIT/
INSPECTION COMPLETED:
06:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Marcela Yanez conducted an unannounced Required 1 Year visit and met with Marie Pendar, Administrator/Licensee. LPA announced the purpose of the visit. LPA observed 4 residents and 3 staff.

During visit, LPA toured the facility inside and out. LPA toured the garage area and observed food storage areas and locked cabinets for cleaning supplies.

LPA observed the kitchen area and observed locked cabinets for medications, During inspection LPA observed the facility kitchen drawer with knives unlocked and accessible to residents in care. LPA observed toxics under kitchen sink unlocked and accessible to residents in care.

LPA observed perishable food supply of at least two days and a non-perishable food supply of at least seven days. Refrigerator temperature measured with thermometer was 40 degrees F.

LPA toured 4 resident bedrooms. Each bedroom had available bedding and clothing storage areas as well as functioning lights. ADM tested the smoke detector in the hallway and found the smoke detector to function properly when tested.

LPA toured two out of two resident bathrooms. Each bathroom had available soap and paper towels and functioning lights. The water temperature in the bathroom sink measured with thermometer at 111 degrees F. The Kitchen sink measured with thermometer at 113 degrees F.
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Romeo ManzanoTELEPHONE: (650) 388-2297
Marcela YanezTELEPHONE: (279) 789-1062
DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2025
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: 07/24/2025
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LPA toured the outside area and found the backyard exit was locked with a pad lock to prevent resident wandering behavior which poses an immediate health, safety or personal rights risk to persons in care. During visit ADM removed the pad lock.

LPA observed fire extinguisher was last serviced on 06/25/25 LPA reviewed Fire and Earthquake log last fire drill was conducted on 05/25/25. The facility has a pull down station fire alarm and was last inspected on 06/25/25.

LPA reviewed resident records for 3 residents. R1 did not have an updated physicians report last report dated 05/25/2023, and Centrally Stored Medication was reviewed with ADM. LPA reviewed 3 staff records.

Deficiencies were cited as per California Code of Regulations Title 22. This report was reviewed with Marie Pendar, Administrator/licensee and a copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Marcela YanezTELEPHONE: (279) 789-1062
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 07/24/2025 05:50 PM - It Cannot Be Edited


Created By: Marcela Yanez On 07/24/2025 at 05:18 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
, 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: 07/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview the licensee did not comply with the section cited above by having a pad lock on the gate exiting from backyard and front yard which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2025
Plan of Correction
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ADM/Licensee will submit a letter of understanding of regulation and inservice training for staff and email LPA proof of correction by poc date 07/25/25
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, the licensee did not comply with the section cited above by having the knives drawer and toxics under sink unlocked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2025
Plan of Correction
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ADMLicensee will submit a letter of understanding of regulation and inservice training for staff and email LPA proof of correction by POC date 07/25/25
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:
TELEPHONE: (650) 388-2297
Marcela Yanez
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: (279) 789-1062
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 07/24/2025 05:50 PM - It Cannot Be Edited


Created By: Marcela Yanez On 07/24/2025 at 05:18 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
, 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: 07/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, resident R3's file did not contain LIC 602 Physician's Report last Physicians Report was on 05/25/23 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2025
Plan of Correction
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Licensee to submit a written plan of action to maintain record of resident's medical assessment. POC will be submitted to LPA by POC due date 07/31/25
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.
Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:
TELEPHONE: (650) 388-2297
Marcela Yanez
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: (279) 789-1062
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2025


LIC809 (FAS) - (06/04)
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