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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701103
Report Date: 01/06/2025
Date Signed: 01/07/2025 09:02:01 AM

Document Has Been Signed on 01/07/2025 09:02 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:PEDROSE HOME CAREFACILITY NUMBER:
392701103
ADMINISTRATOR/
DIRECTOR:		PEDRO PANCHOFACILITY TYPE:
740
ADDRESS:1098 COLLINS STTELEPHONE:
(925) 998-1927
CITY:MANTECASTATE: CAZIP CODE:
95337
CAPACITY: 6CENSUS: 3DATE:
01/06/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Pedro PanchoTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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Unannounced Plan of Correction visit made out to this facility on 01/06/2025 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 12/02/2024:

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).

Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8:
(3) Obtain and evaluate a recent medical assessment.

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: 01/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/06/2025
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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