San Bruno Care Home

Type of visit: POC

On March 26, 2026, Licensing Program Analyst (LPA) Murial Han conducted an unannounced plan of correction visit. LPA met with caregiver, Jennie Pacay and explained the purpose of today's visit. Caregiver informed administrator, Marie Foronda-Cayabyab of LPA's visit. On February 24, 2026 during the annual visit, LPA did not observe a written physician order for 2 over-the-counter medications for resident #5 (R5) and 1 over the counter medication for resident #6 (R6). During today's visit, LPA spoke with the administrator over the phone and reviewed the plan of correction documents that were submitted by the administrator and LPA observed written physician orders were obtained for the above over-the-counter medications. Citation of Incidental Medical and Dental Care Services- 87465(e) is cleared. This report is reviewed and discussed with the caregiver. A copy is provided.the state’s words, verbatim · CDSS document, Mar 26, 2026

Type of visit: Required - 1 Year

On February 24, 2026, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA was greeted by caregivers, Ruben Cabrera and Elizabeth Princesa and LPA explained the purpose of the visit. Administrators, Marie and Chris Cayabyab and Administrator Designee Ninfa Gozon arrived and assisted with the inspection. LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. LPA toured the facility inside and outside including all of resident rooms, common areas, and kitchen area. The indoor and outdoor passageways were free of obstruction. Facility was overall clean and odor-free. Comfortable temperature is maintained and lighting is sufficient for comfort. LPA observed 5 resident rooms (4 private and 1 shared rooms) and 1 staff room. Rooms were spacious and included all required furnishings. Bathroom was observed equipped with paper towels, soap, grab bars, and non-skid mats. Hot water temperature in the kitchen, and bathroom was measured at 105- 118 degree F. Extra linen was present. Medications, toxins and sharps were observed to be locked. 2 days for perishables and & 7 days non-perishable were observed to be present. Facility is equipped with smoke detectors and carbon monoxide detectors. Fire extinguisher were last serviced in 9/9/2025. Fire drill records were reviewed. A review of (6) resident files was conducted and noted on the LIC 858. A review of (2) staff files was conducted and noted on the LIC 859. LPA reviewed P& I/ Case Resource Records for 4 residents to be adequate. During today's inspection, there were 3 residents present and 3 residents were attending the day program. During the tour of the facility, LPA observed the Accessory Dwelling Unit (ADU) in the backyard that was under construction during last year's annual inspection has been completed and is currently being utilized as a living space for two staff members. This observation was confirmed by the administrator/licensee. LPA will proceed with a Fire Clearance Inspection. During the review of medication, LPA observed R5 and R6 have over the counter medications that did not have a written physician order. Deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties. This report is reviewed and discussed with the administrator designee. A copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Feb 24, 2026

Type of visit: Required - 1 Year

On February 11, 2025 Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA was greeted by caregivers, Ruben Cabrera and Elizabeth Princesa and LPA explained the purpose of the visit. Administrators, Marie and Chris Cayabyab arrived and assisted with the inspection. LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. LPA toured the facility inside and outside including all of resident rooms, common areas, and kitchen area. The indoor and outdoor passageways were free of obstruction. Facility was overall clean and odor-free. Comfortable temperature is maintained and lighting is sufficient for comfort. LPA observed 5 resident rooms (4 private and 1 shared rooms) and 1 staff room. Rooms were spacious and included all required furnishings. Bathroom was observed equipped with paper towels, soap, grab bars, and non-skid mats. Hot water temperature in the kitchen, and bathroom was measured at 105- 111 degree F. Extra linen was present. Medications, toxins and sharps were observed to be locked. 2 days for perishables and & 7 days non-perishable were observed to be present. Facility is equipped with smoke detectors and carbon monoxide detectors. Fire extinguisher were last serviced in 8/8/2024. Fire drill records were reviewed. A review of (5) resident files was conducted and noted on the LIC 858. A review of (2) staff files was conducted and noted on the LIC 859. LPA reviewed P& I/ Case Resource Records for 3 residents to be adequate. During today's inspection, there were 3 residents present and 3 residents were attending the day program. During the tour of the facility, LPA observed the facility is under construction in the backyard. According to the administrators/Licensees, the facility has obtained a building permit to build an Accessory Dwelling Unit (ADU) in the backyard. LPA received a copy of the Building Permit and requested for the following documents by 2/15/2025: a copy of the revised facility sketch, a copy of the construction notification to the residents and/or their responsible parties, GGRC, and a copy of the plan to ensure resident's safety during the construction. No deficiency cited today. This report is reviewed and discussed with administrator/licensee. A copy is provided.the state’s words, verbatim · CDSS document, Feb 11, 2025

Type of visit: Required - 1 Year

On 2/8/2024 Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA was greeted by caregiver, Jennie Pacay and LPA explained the purpose of the visit. Administrators, Marie and Chris Cayabyab arrived shortly thereafter to assist with inspection. LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. LPA toured the facility inside and outside including all of resident rooms, common areas, and kitchen area. The indoor and outdoor passageways were free of obstruction. Facility was overall clean and odor-free. Comfortable temperature is maintained and lighting is sufficient for comfort. LPA observed 5 resident rooms (4 private and 1 shared rooms). Rooms were spacious and included all required furnishings. Two full bathrooms were observed to be clean; equipped with paper towels, soap, grab bars, and non-skid mats. Hot water temperature in the kitchen, and bathroom was measured at 106 degree F. Extra linen was present. Medications, toxins and sharps were observed to be locked. 2 days for perishables and & 7 days non-perishable were observed to be present. Facility is equipped with smoke detectors and carbon monoxide detectors. Fire extinguisher were last serviced in 8/31/2023. Fire drill records were reviewed. LPA reviewed 5 resident records and all of them contained Admission Agreement, Medical Assessment- LIC 602 (Physician Order), Appraisal Needs and Service Plan, Resident Identification information, Pre-Placement Appraisals, GGRC/IPP, etc. LPA reviewed 2 staff files and all of them contained Personnel Records, Training Records, Health Screening Records, Job Description, Abuse Statement, First Aid/CPR, Criminal Record Statement, Criminal Background Clearance, etc. LPA reviewed P& I/ Case Resource Records for 4 residents to be adequate. During today's inspection, there were 5 residents present and 1 resident was attending the day program. LPA request for the following documents to be submitted by 2/9/2024: LIC 400 (Affidavit Regarding Client/Resident Cash Resources), Lease Agreement, LIC 308 (Designation of Facility Responsibility), Administrator Certification and Surety Bond. No deficiency cited today. This report is reviewed and discussed with administrators. A copy is provided.the state’s words, verbatim · CDSS document, Feb 8, 2024

Allegation investigated: Alteration to Existing Building Fire Safety

On November 15, 2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced complaint visit. LPA met with caregivers, Ruben Cabrera and Jennie Pacay and explained the purpose of the visit. The administrator, Marie Cayabyab arrived toward the end of the visit and met with LPA. During today's visit, LPA toured the facility , interviewed administrator and facility staff. During the tour, LPA observed a living space/loft in the garage and an Accessory Dwelling Unit (ADU) in the backyard. Both of these observations were not included in the facility sketch that was submitted to CCL. In addition, there were "yellow tags" on the doors of both these locations that was placed by the City Of San Mateo Code Enforcement on 11/8/2023 after they were determined to be inhabitable space. Substantiated According to staff #1 (S1), the loft in the garage attic was a living space for S1 and staff # (2) S2 and the Accessary Dwelling Unit (ADU) in the backyard was a living space for staff # 3(S3) who was an on-call staff, but when S3 was informed that he/she could no longer stay there about a couple weeks ago, he/she stop working at the facility. According to S1 and staff # 4 (S4), they did not know when the garage attic and the ADU were build but they stated that the garage attic was used for isolation for staff who tested possible for COVID-19 during the pandemic. According to the administrator, the garage attic and the ADU were intended to be used for staff isolation during the Pandemic and they continued to be used as such after the Pandemic. In addition, the administrator stated they are in process of getting a building permit for the ADU. Based on observations, and interviews during the investigation, the preponderance of evidence standard has been met. Therefore, this allegations were determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with the administrator. A copy is provided and Appeal Rights.the state’s words, verbatim · CDSS document, Nov 15, 2023 · control 14-AS-20231108103204

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87305(a) · Plan of correction due date: Nov 16, 2023

87305 Alterations to Existing Building or New Facilities..(a) Prior to construction or alterations, all facilities shall obtain a building permit. This requirement is not met as evidenced by facility build a living space in the garage attic and a ADU in the backyard without obtaining a building permit which poses an immediate health risk for residents in care.the state’s words, verbatim · CDSS document, Nov 15, 2023

Plan of correction: Licensee to submit a written plan in writing to address the garage attic and the ADU until proper building permit(s) is obtaining. Licensee will submit a copy of the written plan to CCL by 11/16/2023.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Nov 16, 2023

87203 Fire Safety..All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by facility staff members were occupying the ADU and the garage attic as living space prior to obtaining proper fire clearance which poses an immediate health risks to residents in care.the state’s words, verbatim · CDSS document, Nov 15, 2023

Plan of correction: Licensee to submit a written plan in writing to address how to provide habitable living accommodations for staff until proper fire clearance has been obtained. Licensee will submit a copy of the written plan to CCL by 11/16/2023.