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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701103
Report Date: 10/31/2025
Date Signed: 10/31/2025 03:24:11 PM

Document Has Been Signed on 10/31/2025 03:24 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/
DIRECTOR:		PEDRO PANCHOFACILITY TYPE:
740
ADDRESS:1098 COLLINS STTELEPHONE:
(925) 998-1927
CITY:MANTECASTATE: CAZIP CODE:
95337
CAPACITY: 6CENSUS: 4DATE:
10/31/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst, LPA, Noel Wolf Petersen and Licensing Program Manager, LPM, Liza King arrived unannounced at 10:45am to conduct an annual inspection. Pedrose Home Care, is a 6 capacity facility for 5 nonamb and 1 bedridden. There is 3 resident on hospice, 2 residents who are bedridden and 3 residents with dementia. Facility is observed to have 2 bedridden clients, operating outside the license and beyond the buildings fire clearance, citations issued on following d-page.

Physical Plant inspection was conducted including but not limited to kitchen, common areas, bedrooms, bathrooms, storage areas, staff room, exteriors, and evacuation routes. facilility is clean and traffic areas are unobstructed and well lit.

Kitchen, has adequate food supply 2 days perishable, 7 days non perishable. Sharps, Medications, are stored locked.

common areas and exterior have space for activities and free of trip hazards.

Evacuation route gate is in good repair, swings freely and latches closed.

bathrooms have functioning hardware, water is delivered within range 105-120*F.

Bedrooms have required furniture and furnishings, mattresses are have rubber encasements.

Continued on c Page.
NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 10/31/2025 03:24 PM - It Cannot Be Edited


Created By: Noel Wolf Petersen On 10/31/2025 at 11:51 AM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PEDROSE HOME CARE
FACILITY NUMBER: 392701103

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87633(b)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above in 2 out of 3 hospice residents do not have a hospice care plan in their file which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/06/2025
Plan of Correction
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The licensee has agreed to contact the hospice agencies, request a copy of the care plans and address the needs of the resdient and services provided by hospice in the Needs and Services plan. send to charlie.yang@dss.ca.gov.
Type A
Section Cited
CCR
87202(a)(2)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and reocord review, the licensee did not comply with the section cited above in 2 out of 4 residents were observed to be bedridden which means they required assistance positioning which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2025
Plan of Correction
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The licensee will develop a plan and submit to Charlie.Yang@dss.ca.gov by the POC date
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Noel Wolf Petersen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/31/2025 03:24 PM - It Cannot Be Edited


Created By: Noel Wolf Petersen On 10/31/2025 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PEDROSE HOME CARE
FACILITY NUMBER: 392701103

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87463(b)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in that 2 of 4 residents had outdated Needs and Services Plans, 2 of 4 had unsigned needs and services plans, 3 of 4 needs and services plans did not address hosice needs owhich poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2025
Plan of Correction
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The licensee agreed to update the Needs and Service Plans of each of the residents addressing the current needs and services being provided by other agencies such as home health and hospice. Sent to charlie.yang@dss.ca.gov
Type A
Section Cited
CCR
87465(c)(3)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that 4 of 4 resident records revaeled that the resdients response to the prn medication was not documented nor was the time of day documented which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/01/2025
Plan of Correction
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The licensee agrees to update the MAR to address reason results and person provideing. A template was provided by the LPA during the time of visit via email to pedroscarehome@gmail.com
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Noel Wolf Petersen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2025


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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: PEDROSE HOME CARE
FACILITY NUMBER: 392701103
VISIT DATE: 10/31/2025
NARRATIVE
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Smoke/Co alarm was functional, Fire extinguisher was dated 6/9/25, first aid kit is complete. air temp is 69*f.

4 of 4 client files are not up to date, 2 of 3 hospice care plans not present, however interview with administration showed not familiar with hospice care plans. 4 of 4 needs and services care plans were not individualized and/or present. citation issued on following d-page.

3 of 5 Staff files contain up to date cpr/ first aid, finger printing, guardian association, and initial training. partial continuing training 12/20 hours completed for the year 2025. Administrator was advised hospice can provide free additional training(medication administration/documentation) specific to dementia/hospice care. citation was given on following d-page.

Clients have no P+I. Safeguarded property forms are not filled out for all clients, Technical violation was issued. 2 staff was interviewed, 2 clients were interviewed.

Medication and mars were reviewed for 2 clients at random: there are no start dates on medications, mars are not up to date with the administrated medications for the past 3 days, the prn/refusal documentation does not have required information, the disposal documentation exists but doesn't apply to any residents currently in the facility who have had medications discontinued. LPA gave guidance that the administrator should assert a role of care giving with the clients at a level where they can call the doctors of the clients directly in the event that changes in care need to be responded to. One client has medications stored outside their original containers. Citations were given on following d-page.

Administrator files were reviewed: fire drill record doesn't exist, liability insurance is up to date, no need for surety bond, refund and theft and loss policy exists in the plan of operation, property control exists via grant deed, 308 does not designate a person, secretary of state is expired. Citation issued on following d page.

LPA is requesting an updated 200(for 2 bedridden), facility sketch(for 2 bedridden), 308(designating a substitute administrator), and a copy of up to date workers comp insurance, filings with secretary of state, safeguarded property for all clients. LPA is giving guidance that an outside agency should give the training for medication documentation and administration.

Copy of the report was read and given to the administrator. exit interview was conducted. citations were given as part of this visit. appeal rights were provided. TSP refferal was offered.
NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2025
LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 10/31/2025 03:24 PM - It Cannot Be Edited


Created By: Noel Wolf Petersen On 10/31/2025 at 02:19 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PEDROSE HOME CARE
FACILITY NUMBER: 392701103

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 3 staff records reviewed which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/01/2025
Plan of Correction
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Within the Poc Date, the licensee will provide evidence of training, in the approprite topics, via ceritfication to charlie.yang@dss.ca.gov.
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.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Noel Wolf Petersen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/31/2025 03:24 PM - It Cannot Be Edited


Created By: Noel Wolf Petersen On 10/31/2025 at 02:19 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PEDROSE HOME CARE
FACILITY NUMBER: 392701103

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(b)
Other Provisions
(b) A facility shall provide training on the plan to each staff member upon hire and annually thereafter. The training shall include staff responsibilities during an emergency or disaster.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and staff interview, the licensee did not comply with the section cited above in 1 out of 2 staff interviewed and 0 out of 1 fire drill records present which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/01/2025
Plan of Correction
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Fire Drill will occur within the next 30 days, a copy of the fire drill record will be sent to charlie.yang@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Noel Wolf Petersen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2025


LIC809 (FAS) - (06/04)
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