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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701103
Report Date: 12/10/2021
Date Signed: 12/13/2021 09:58:07 AM

Document Has Been Signed on 12/13/2021 09:58 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:PEDROSE HOME CAREFACILITY NUMBER:
392701103
ADMINISTRATOR:MABUNGA, JOYCE MAEFACILITY TYPE:
740
ADDRESS:1098 COLLINS STTELEPHONE:
(925) 998-1927
CITY:MANTECASTATE: CAZIP CODE:
95337
CAPACITY: 6CENSUS: 0DATE:
12/10/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Pedro Pancho and Joyce Mae MabungaTIME COMPLETED:
12:00 PM
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Announced Prelicensing visit made out to this facility on 12/10/2021 by LPA Charlie Yang. This LPA was met by the Applicant, Pedro Pancho, and the facility designated Administrator Joyce Mae Mabunga.
Current census was zero residents.
This Applicant is seeking licensure for 6-bed RCFE with a hospice waiver for (6) residents and dementia program.
Tour of this facility was conducted.
Resident bedrooms were toured. Furnishings and furniture were observed to be sufficient and in compliance at this time.
Resident restrooms were toured. Grab bars and non skid mats were observed to be present and in compliance at this time. Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees.
Medication cabinet, located in hallway, was reviewed. First aid kit was observed to be present and contained all of the required components at this time.
Kitchen area was toured. Drawers and cabinets were reviewed. Cook ware, glassware, and all other utensils were observed to be sufficient and able to meet the needs of the residents at this time.
Cabinet used to store and maintain knives was observed to be locked and made inaccessible to the residents at this time.
Living area, dining area, and all other areas designated for resident use were observed to be furnished and maintained in compliance at this time.
Laundry area was toured. Door leading to this area was observed to be locked and made inaccessible to the residents at this time.
Garage area was toured. Cabinets were observed to store and maintain linens and other supplies intended for resident use.
Fire extinguisher, located in kitchen area, was observed to have been purchased on 11/18/2021 with receipt attached.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: PEDROSE HOME CARE
FACILITY NUMBER: 392701103
VISIT DATE: 12/10/2021
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Exterior grounds of this facility were toured.
Perimeter fence and side gate was observed to be maintained in compliance at this time.
This LPA did observe the presence of a jacuzzi which was fenced off and locked making it inaccessible to the residents at this time.
A review of the (7) day non perishable food supplies was conducted and observed to be in compliance at this time.

This facility and its Applicant has been found to be in compliance at this time.

Exit Interview
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021
LIC809 (FAS) - (06/04)
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