Pacific Care Home V

Type of visit: Required - 1 Year

On 04/10/2025, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced required 1 year inspection. LPA met with co-administrator Moddie Andaya and explained the purpose of today's visit. Currently there are 6 residents in place and 3 staff in place. Around 10:30am the administrator Moddie Andaya arrived. The facility is licensed for age range 60 and over. All may be non-ambulatory, of which one may be bedridden. Hospice waiver approved for 2. Bedroom 5 is approved for bedridden. There currently 2 residents under hospice and no bedridden residents according to staff. This is a single level facility. Facility temperature is comfortable for residents in care. Facility emergency food supplies such as canned goods are in a large storage closet located in the garage. Additional supplies are in the garage as well. There are 6 resident rooms. Water temperature is tested in the common full bath where residents shower. It was measured at 110F. Cleaning supplies in the kitchen are observed as locked beneath the kitchen sink. Additional cleaning supplies are locked in the garage in a large storage cabinet. Facility knives are observed to be locked in a drawer across from the stove/cooking range. Kitchen food supplies are observed to be in place with 2 day fresh food supply and canned goods fulfilling the 7 day emergency food supply. A tour of the outside of the facility is conducted. Continued on next page... Page 2 Emergency routes are free and clear of any obstructions. Smoke detectors and carbon monoxide detectors are located through out the facility. The facility is also equipped with 2 fire alarm pull stations, one in the front, and one in the back of the facility. LPA observed 2 fire extinguishers in the facility with inspection tags dated 03/09/2026. Facility conducts emergency drill quarterly. The last drill that was conducted is logged with a date of 02/10/2026. Linens are in place for resident use stored in a hallway closet and in resident rooms. LPA observed all resident rooms and observed that they contain the required furniture and lighting as outlined in Title 22. Medications, medical kit, are stored in locked medication closet in the main hallway. Toilet and bathing facilities are equipped with grab bars and nonskid flooring material. Hygiene supplies are in place. LPA reviewed staff and resident files on this day which appear to be current based on review. Staff training records are observed to be current and in place. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed as current. 6 of 6 resident medications are reviewed and are current and logged per review. Administrator certificate for Moddie Andaya is observed as current expiring 11/15/2027. Report is reviewed with Moddie Andaya and a copy of is provided on this day. No citations issued.the state’s words, verbatim · CDSS document, Apr 28, 2026

Type of visit: Required - 1 Year

On 04/10/2025, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced required 1 year inspection. LPA met with co-administrator Moddie Andaya and explained the purpose of today's visit. Currently there are 6 residents in place and 3 staff in place, one of which is the administrator. The facility is licensed for age range 60 and over. All may be non-ambulatory, of which one may be bedridden. Hospice waiver approved for 2. Bedroom 5 is approved for bedridden. There currently are no hospice and no bedridden residents according to staff. This is a single level facility. Facility temperature is comfortable for residents in care. Facility emergency food supplies such as canned goods are in a large storage closet located in the garage. Additional supplies are in the garage as well. There are 6 resident rooms. Water temperature is tested in the common full bath where residents shower. It was measured at 106F. Water temperature was also tested in room #3 at 106F as well. Cleaning supplies in the kitchen are observed as locked beneath the kitchen sink. Additional cleaning supplies are locked in the garage in a large storage cabinet. Facility knives are observed to be locked in a drawer across from the stove/cooking range. Kitchen food supplies are observed to be in place with 2 day fresh food supply and canned goods fulfilling the 7 day emergency food supply. A tour of the outside of the facility is conducted. Emergency routes are free and clear of any obstructions. Smoke detectors and carbon monoxide detectors are located through out the facility. The facility is also equipped with 2 fire alarm pull stations, one in the front, and one in the back of the facility. LPA observed 2 fire extinguishers in the facility with inspection tags dated 03/20/2025. Facility conducts emergency drill quarterly. The last drill that was conducted is logged with a date of 02/19/2025. Linens are in place for resident use stored in a hallway closet and in resident rooms. Continued on next page... Page 2 LPA observed all resident rooms and observed that they contain the required furniture and lighting as outlined in Title 22. Medications, medical kit, are stored in locked medication closet in the main hallway. Toilet and bathing facilities are equipped with grab bars and nonskid flooring material. Hygiene supplies are in place. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed as current. LPA reviewed staff and resident files on this day which appear to be current based on review. Staff training records are observed to be current and in place. Administrator certificate for Moddie Andaya is observed as current expiring 11/15/2025. Report is reviewed with Moddie Andaya. A copy of this report is provided to the facility. No citations issued.the state’s words, verbatim · CDSS document, Apr 10, 2025

Type of visit: Required - 1 Year

LPA Audrey Jeung toured facility and grounds. There are 6 private client rooms--2 of which have private bathrooms--a staff room, 2 common bathrooms, living/dining area, kitchen, and 2-car garage, where the washer and dryer are located. There is a daybed in the garage which is used by staff on breaks. No accessible bodies of water or fire safety hazards observed. PPE supply is adequate. 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. A Disaster and Mass Casualty Plan is posted. There are 6 residents present, and 3 staff. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, as well as staff records. Moddie Andaya and Billy Ick (x 3/24 ) are certified RCFE administrators that oversee facility operations. Client records, including medications are reviewed. The following updated forms are requested to be submitted to CCLD BY 5/17/24: • LIC 308 Designation of Administrative Responsibility • LIC 500 Personnel Report (including specific hours when administrators are present in facility) • LIC 309 Administrative Organization Proof of current liability insurance is given to LPA today. Deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed and cited on a following page. See also Advisory Notes--4 pages.the state’s words, verbatim · CDSS document, May 3, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: May 3, 2024

INCIDENTAL MEDICAL CARE 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 hall cabinet where medications are secured is unlocked upon LPA's arrival. Also, Clearlas for client 2 & Miralax for client 5 are stored in unlocked kitchen cabinet. Licensee failed to ensure that medications are inaccessible to clients, which poses an immediate health and safety risk to clients in care.the state’s words, verbatim · CDSS document, May 3, 2024

Plan of correction: Medications cabinet was locked and Miralax and Clearlax were secured in medications cabinet in LPA's presence. Deficiency corrected and cleared.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87355(e)(2) · Plan of correction due date: May 3, 2024

CRIMINAL BACKGROUND CLEARANCE All individuals subject to a criminal record review pursuant to HSC 1569.17(b) shall prior to working, residing or volunteering in a licensed facility, request a transfer of a criminal record clearance as specified in Section 87355(c). This requirement was not met, as staff #1 does not have criminal record clearance associated to this facility. Licensee failed to ensure that all staff have criminal record clearance associated to facility, which poses an immediate health and safety risk to clients in care.the state’s words, verbatim · CDSS document, May 3, 2024

Plan of correction: Request to transfer criminal record clearance for staff #1 and photo ID are given to LPA for processing. Deficiency corrected and cleared

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c)(1) · Plan of correction due date: May 17, 2024

PERSONNEL REQUIREMENTS Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement was not met, as staff #1 and #2 do not have current first aid training. Licensee failed to ensure that caregivers have current first-aid training, which poses a potential health, safety, or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, May 3, 2024

Plan of correction: Proof of current first aid training for S1 and S2 will be sent to CCLD BY DUE DATE

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct an annual required inspection. LPA met with facility staff Melody Corpuz, and explained the purpose of the visit. Facility staff contacted Administrator Moddie Andaya, which stated he will arrive after completing a Christmas Party for another care home. Administrator Moddie arrived later during the visit to meet with LPA Valerio. LPA Valerio and facility staff toured the physical plant to ensure compliance with Title 22 regulations. LPA inspected 6 resident bedrooms, 1 staff area, kitchen area, common area, 2 bathrooms, garage area, and exterior plant. Resident bedrooms were equipped with required furniture, were observed to be clean without any odors, and free from debris. The kitchen was observed to be clean and to have sharps locked away and inaccessible to residents. The facility was observed to have a minimum of 2 days of perishable food items, 7 days of non-perishable food items, and an emergency supply of food. Bathrooms were equipped with non-skid mats, toilet paper, paper hand towels, soap, and a trash can. Hot water temperature was measured between the regulatory range of 105.0*F - 120.0* degrees F. Fire extinguishers were observed to be fully charged with an annual inspection on 03/03/2023. LPA observed the exterior plant to be clean, have areas for outside visits, and to have no obstructions of emergency exits. LPA spoke to facility staff and a resident during the visit. Staff were observed cleaning the facility, checking in on residents, and assisting with a facility visitor. Residents were observed dancing in a chair to Christmas music, watching television, and taking a nap. LPA reviewed staff files and resident files. LPA observed 2 staff files to be current with up to date training. Three (3) resident files were reviewed. 1 out of 3 resident files were observed to be incomplete. LPA requested the following documentation be sent to the San Bruno Regional Office: LIC 309 Administrative Organization, LIC 500, LIC 308, LIC 610E, and Copy of Liability Insurance. Per California Code of Regulations (CCR) - Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached LIC 809 - D. Appeal Rights were provided. An exit interview was held with Administrator Moddie, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 15, 2023