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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294025
Report Date: 02/07/2023
Date Signed: 02/07/2023 12:16:09 PM


Document Has Been Signed on 02/07/2023 12:16 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:
435294025
ADMINISTRATOR:MILA VALISTOFACILITY TYPE:
740
ADDRESS:524 SAFARI DRIVETELEPHONE:
(408) 578-8488
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY:6CENSUS: 2DATE:
02/07/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Mila ValistoTIME COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to open an initial complaint investigation. During visit, LPA conducted a case management - deficiencies visit. LPA met with Administrator (ADM), Mila Valisto.

During visit, LPA toured the facility with the ADM to include the resident bedrooms and exterior.

At 10:00AM, LPA observed resident (R1) had bed rails that exceeded half the length of the bed. LPA observed resident (R2)'s hospital bed with half bed rails. Based on record review, R1 and R2 did not have a written physician's order for the bed rails nor is receiving hospice care.

At 10:05AM, LPA observed more than three extension cords plugged in to one another that ran to the corner of the backyard. The main extension cords was plugged into multiple outlets inside facility. At 10:06AM, LPA observed a shed with a tarp and hanged clothing covering the corner of the backyard. Upon entering the area, LPA and ADM observed a microwave, refrigerator, table, chairs, rice cooker, coffee machine, portable stove-top with pots and pans, food items, vitamins, and shoes. Staff (S1) unlocked the shed and inside LPA observed a bed, linens, clothing, and other personal belongings. Based on interview, the shed was being used for sleeping purposes. Based on observation, the extension cord was powering the kitchen appliances in the backyard which may cause a fire hazard.

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. Advisory note provided. See LIC9102. Plan of corrections were developed with ADM and a copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2023
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 3


Document Has Been Signed on 02/07/2023 12:16 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: 435294025

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/14/2023
Section Cited

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(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by:
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During visit, Administrator called R1 - R2's family to request for a written physician's order. Licensee will obtain a written physician's order for the bed rails. Licensee will send the plan to obtain the physician's order and statement of understanding of section 87608 to LPA via email by POC due date.
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Based on interview, observation, and record review, 2 out of 2 residents hospital beds contained bed rails without a written physician's order 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.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 02/07/2023 12:16 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: 435294025

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/08/2023
Section Cited

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(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: This requirement is not met as evidenced by:
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Licensee will ensure to provide proper and comfortable living accomodations for their staff. Licensee immediately removed the bed and all personal belongings in the shed and backyard area.
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Based on observation and interview, the staff was not being provided a proper and comfortable living arrangement at the facility by sleeping inside the shed which poses an immediate health, safety, and personal rights risk to persons in care.
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Licensee will review section 87307 and send a statement of understanding to LPA via email by POC due date.
Type A
02/08/2023
Section Cited

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(d) The following space and safety provisions shall apply to all facilities:(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.
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Licensee immediately removed all the extension cords that ran through the backyard. Licensee will send a statement of understanding to ensure the facility will be kept in a safe and healthful enviornment to LPA via email by POC date .
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Based on observation and interview, LPA observed more than three extension cords plugged into one another that was being used to run kitchen appliances at the corner of the backyard 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.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3