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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701103
Report Date: 12/07/2022
Date Signed: 12/09/2022 02:59:48 PM

Document Has Been Signed on 12/09/2022 02:59 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
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: 2DATE:
12/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Pedro PanchoTIME COMPLETED:
12:30 PM
NARRATIVE
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Unannounced annual visit made out to this facility on 12/07/2022 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Pedro Pancho. Brief interview was conducted with the facility designated Administrator at this time.
Current census was (2) residents.
It was learned that there was one resident under the care of hospice at this time. This facility does have a waiver to accept and retain up to (6) residents under hospice care.
Tour of the facility was conducted.
Kitchen area was toured. Cabinets and drawers were reviewed to make sure that there was a sufficient supply of plates, silverware, and items necessary to meet the needs of the residents at this time.
A review of the facility food supply was conducted to make sure that there was an adequate 2-day perishable and 7-day nonperishable amounts at all times. Pantry area was toured.
Cleaning supplies and agents were observed to be present under the kitchen sink cabinet and were locked and made inaccessible to the residents at this time.
Dining area, living area, and all other areas intended for resident use were observed to be furnished and maintained in compliance at this time.
Fire extinguisher, located hanging in facility entry way, was observed to have been purchased on 11/13/2022 from The Home Depot at this time.
A tour of the facility resident rooms was conducted. Bedroom furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
A tour of the facility resident restrooms was conducted. Grab bars and non skid mats were observed to be in place and able to serve the needs of the residents at this time.
Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees at all times.
Laundry area was toured. Cabinets housing detergents, bleach, and all other laundry supplies were observed to be behind a door that could be locked to make these items inaccessible to the residents at all
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2022
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: 12/07/2022
NARRATIVE
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times.
A tour of the facility garage area was conducted. Cabinets housing additional items for resident use were reviewed. Additional linens, seasonal supplies, and cleaning agents were observed to be stored behind a door leading into this area that was locked to make it inaccessible to the residents at this time.
Linen closet was observed to contain the necessary supplies and items in order to meet the needs of the residents at this time.
Medication cabinet, located in entry way cabinet, was reviewed. Policies and procedures for handling, dispensing, and documentation of the resident medications were reviewed with the facility designated Administrator at this time. A review of the facility medication administration record (MAR) was conducted.
First aid kit was present and observed to contain all of the required components at this time.
A tour of the facility exterior grounds was conducted. A review of the facility perimeter fence, side gate, and exits was conducted.

The following forms and documents were requested to be updated and submitted into CCL for review by this LPA:
  • LIC 308

  • LIC 400

  • LIC 500

  • LIC 610

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes.

Appeal rights were printed and a copy was given to the facility designated Administrator Pedro Pancho at this time.

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

DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022
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Document Has Been Signed on 12/09/2022 02:59 PM - It Cannot Be Edited


Created By: Charlie Yang On 12/07/2022 at 12:19 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PEDROSE HOME CARE
FACILITY NUMBER: 392701103

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in [2] out of [2] bathroom sinks delivering hot water at the temperature of 135.8 degrees which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/08/2022
Plan of Correction
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Facility designated Administrator Pedro Pancho stated that the hot water heater will be reviewed turned down to deliver hot water within the allowed range of 105-120 degrees at all times. A statement of correction, and log of temperatures taken for at least 24 hours, will be completed and submitted into CCL by the due date of 12/08/2022.
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.
SUPERVISOR'S NAME:Stephenie Doub
LICENSING EVALUATOR NAME:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/09/2022 02:59 PM - It Cannot Be Edited


Created By: Charlie Yang On 12/07/2022 at 12:19 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PEDROSE HOME CARE
FACILITY NUMBER: 392701103

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above since unused building materials were left around the side of the house which needed to be removed and discarded. In addition, the side gate latch was not in functional order and was in need of repair to properly secure the perimeter which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/14/2022
Plan of Correction
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Facility designated Administrator Pedro Pancho stated that the unused building materials around the side of the house will be removed. The facility designated Administrator stated that the side gate exit will be repaired/replaced to make sure that it closed and opened properly with a functional latch to secure the perimeter at all times. A statement of correction, along with photos of the cleared side yard and updated gate latch, will be completed and submitted into CCL by the due date of 12/14/2022.
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.
SUPERVISOR'S NAME:Stephenie Doub
LICENSING EVALUATOR NAME:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2022


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