<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601081
Report Date: 05/19/2021
Date Signed: 05/21/2021 11:02:13 AM

Document Has Been Signed on 05/21/2021 11:02 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:PACIFIC CARE HOME VFACILITY NUMBER:
415601081
ADMINISTRATOR:ANDAYA, MODDIEFACILITY TYPE:
740
ADDRESS:1790 BROOKS STTELEPHONE:
(650) 315-2152
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY: 6CENSUS: 5DATE:
05/19/2021
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Moddie Andaya and Raffy JisonTIME COMPLETED:
04:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
LPA Audrey Jeung toured facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. PPE supply is adequate. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Toilet and bathing facilities are equipped with grab bars and nonskid flooring material. Soap and paper towels--or cloth towels in private bathrooms--are available at all sinks. First-aid kit is inspected and complete. An updated Disaster and Mass Casualty Plan is readily available. There are 5 residents present, and 4 staff. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Moddie Andaya and Billy Ick are certified RCFE administrators (x11/21 and x3/22 ) that oversee facility operations.

The following updated forms are requested to be submitted to CCLD BY 5/26/21:

• LIC 308 Designation of Administrative Responsibility
• LIC 500 Personnel Report

Proof of current liability insurance is given to LPA today.

Mr. Andaya is advised that Personal Rights form (LIC613C-2) has been revised to include Health and Safety Code 1569.269, non-discrimination (LGBTQ) notice, AND Centralized Complaint and Information Bureau (CCIB) contact information. This information must be posted prominently in facility, and LIC613C-2 must be signed by resident or his/her representative.

Deficiency of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 is observed and cited on a following page.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 05/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2021
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 2
Document Has Been Signed on 05/21/2021 11:02 AM - It Cannot Be Edited


Created By: Audrey Jeung On 05/19/2021 at 03:44 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: PACIFIC CARE HOME V
FACILITY NUMBER: 415601081

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks.  Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure.  A report shall be made of each screening, signed by the examining physician.  The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents.  A signed statement shall be obtained from each volunteer affirming that he/she is in good health.  Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above, as 3 out of 5 staff do not have health screenings and/or TB test results on file, which poses a potential health, safety or personal rights risk to persons in care.

Staff CB and HC do not have health screenings and TB test results on file. Staff MS does not have TB test results on file.
POC Due Date: 06/02/2021
Plan of Correction
1
2
3
4
Proof that 4 staff have health screenings and/or TB test results on file will be sent to CCLD BY DUE 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.
SUPERVISOR'S NAME:Julio Montes
LICENSING EVALUATOR NAME:Audrey Jeung
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2021


LIC809 (FAS) - (06/04)
Page: 2 of 2