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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801057
Report Date: 02/19/2026
Date Signed: 02/19/2026 12:01:29 PM

Document Has Been Signed on 02/19/2026 12:01 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:BAY OSOS RCFE IFACILITY NUMBER:
405801057
ADMINISTRATOR/
DIRECTOR:		RODOLFO PACAOANFACILITY TYPE:
740
ADDRESS:1663 13TH STREETTELEPHONE:
(805) 528-4416
CITY:LOS OSOSSTATE: CAZIP CODE:
93402
CAPACITY: 6CENSUS: 3DATE:
02/19/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:13 AM
MET WITH:Alternate Administrator, Rosemarie LunaTIME VISIT/
INSPECTION COMPLETED:
12:24 PM
NARRATIVE
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 At 8:15am on 02/19/2026, Licensing Program Analyst (LPA) Jeffries arrived to the facility unannounced to conduct the facility annual inspection. LPA met with Alternate Administrator, Rosemarie Luna, announced who he is and the reason for the visit. Assigned Administrator Rodolfo Pacaoan is currently out of the country.
This is a four bedroom, two bathroom, facility with two living rooms, dining room and kitchen, there is an out door area in the back and front of the facility with seating and shade for residents with visitors and activities. Three of the bedrooms are double resident occupancy and the forth bedroom is dedicated for overnight staff. LPA observed resident bedrooms to be properly furnished with proper linin and utilities in working operations. LPA observed liquid soap and paper towels in the two bathrooms that are available to all clients and staff. LPA noted that during the physical tour over the counter medication was discovered unsecured in bedroom #2 and a subsequent citation was issued (87465(h)(2)). LPA noted that files and medication are locked in a lockable filing cabinet adjacent to secondary living room. LPA noted that there is a complete first aide kit and a working fire extinguisher between the dining room and the secondary living room. LPA observed at least two days of perishable foods and at least seven days of nonperishable foods on hand for six residents and staff. LPA tested carbon monoxide detectors and smoke detectors all to be functioning. LPA noted that all hallways, door ways, and exits were free and clear of debris. LPA conducted a file review of staff and resident files. LPA reviewed facility emergency disaster plan and infection control plan. LPA verified facility liability insurance. Alternated Administrator and LPA conducted a full review of the annual care tools module and noted no other violation than the one mentioned above. At this time there is a single violation and no other issues during this annual facility inspection.
Exit interview, report read, appeal rights and report provided.
NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Mark Jeffries
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/19/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
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 02/19/2026 12:01 PM - It Cannot Be Edited


Created By: Mark Jeffries On 02/19/2026 at 11:44 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BAY OSOS RCFE I
FACILITY NUMBER: 405801057

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/19/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in [count] out of 4 count of 11 objects of OTC medications] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/20/2026
Plan of Correction
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Administrator agrees to conduct medication safety training for all staff within 14 days. Administrator will notify LPA within 24 hours a list of all staff that will take the training and the training material used for the 1 hour training. LPA provided email with Administrator.
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.
Kelly Burley
NAME OF LICENSING PROGRAM MANAGER:
Mark Jeffries
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/19/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/19/2026


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 02/19/2026 12:01 PM - It Cannot Be Edited


Created By: Mark Jeffries On 02/19/2026 at 11:44 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BAY OSOS RCFE I
FACILITY NUMBER: 405801057

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/19/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(4)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation the licensee did not comply with the section cited above in [count] out of 1 count (medication bottle) with approximately 7 pills which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/05/2026
Plan of Correction
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Administrator agrees to conduct medication safety training for all staff within 14 days. Administrator will notify LPA within 24 hours a list of all staff that will take the training and the training material used for the 1 hour training. LPA provided email with Administrator.
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.
Kelly Burley
NAME OF LICENSING PROGRAM MANAGER:
Mark Jeffries
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/19/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/19/2026


LIC809 (FAS) - (06/04)
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