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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701103
Report Date: 12/07/2023
Date Signed: 12/08/2023 04:51:58 PM

Document Has Been Signed on 12/08/2023 04:51 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
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:
12/07/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Pedro PanchoTIME COMPLETED:
11:30 AM
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Unannounced Plan of Correction visit made out to this facility on 12/07/2023 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Pedro Pancho, at this time. A brief interview was conducted with the facility designated Administrator at this time.
The purpose of this visit was to follow up on the deficiencies that were cited on a prior annual visit dated on 11/27/2023:

An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. (1) The Infection Control Plan shall include all of the following: (C) An Infection Control Training Plan. 1. Initial training requirements for new facility staff shall be addressed in the plan, with training to be provided by the Infection Control Lead before staff works independently with residents.

An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. (1) The Infection Control Plan shall include all of the following: (C) An Infection Control Training Plan. 2. Ongoing training requirements for all facility staff shall be addressed by the plan, with training to be provided by the Infection Control Lead.

The Plan of Correction was reviewed and clearance letter was printed out and a copy was given to the facility designated Administrator at this time.

There were no deficiencies observed or cited during today's visit.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2023
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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