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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 02:58:59 PM

Document Has Been Signed on 12/09/2022 02:58 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:Post LicensingUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Pedro PanchoTIME COMPLETED:
01:30 PM
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Unannounced post licesning 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
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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.

All deficiencies were cited and delivered on the joint annual visit.

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
LIC809 (FAS) - (06/04)
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