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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801055
Report Date: 04/22/2025
Date Signed: 04/22/2025 11:44:13 AM

Document Has Been Signed on 04/22/2025 11:44 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:BAYWOOD MANOR RCFE IIFACILITY NUMBER:
405801055
ADMINISTRATOR/
DIRECTOR:		GUILLERMA M.PACAOANFACILITY TYPE:
740
ADDRESS:1090 PASO ROBLES AVENUETELEPHONE:
(805) 528-5305
CITY:LOS OSOSSTATE: CAZIP CODE:
93402
CAPACITY: 6CENSUS: 4DATE:
04/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:18 AM
MET WITH:Administrator, Guillerma Pacaoan,TIME VISIT/
INSPECTION COMPLETED:
11:59 AM
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 At 8:20am on 04/22/2025, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct the annual facility inspection. LPA met with Administrator, Guillerma Pacaoan, announced who he is and the reason for the visit.

Administrator and LPA conducted a full tour of the facility inside and outside. LPA noted that this is a 3 bedroom and two bathroom facility, One bedroom is designated for dual resident occupancy and the other two rooms are for single resident occupancy. there is a garage, laundry room, living room, kitchen and dining room. There is a covered porch that wraps around the back and side of the facility that provides seating and shade for residents and visitors. LPA noted that each room is furnished per licensing regulations. Both bathrooms have paper towels and liquid soap. Water tested in both bathrooms and kitchen, all to be within licensing regulations temperature (105*-120* (f)). LPA noted that there is a fire extinguisher in the kitchen that is primed and in the green. LPA tested all smoke detectors and carbon monoxide detectors to be working and were tested during facility annual inspection. LPA noted that the medications and files are locked in the living room area in locked cabinets. LPA noted that there is a complete first aide kit. LPA noted that the door ways and passage ways in the facility were free and clear of obstacles and debris. LPA reviewed all staff and resident files all to be completed and training up to date. LPA reviewed Infection control plan, emergency disaster plans and emergency drill logs. LPA conducted a review of Centrally Stored Medication Records (CSMR) and found no errors. LPA conducted a full review of the annual care tool modules. During this annual facility inspection LPA found no violations and no citations.
Exit interview, report read, and report provided.
NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Mark Jeffries
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/22/2025
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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