South Bay Residential Home

Type of visit: Required - 1 Year

On March 23, 2026, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with administrator Editha Pacleb. LPA explained the purpose of today’s visit. The facility is licensed to operate for six (6) non-ambulatory elderly adults ages 60 and above. The facility is approved for four (4) hospice waiver. Currently, there is one (1) hospice resident. The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) residents' rooms, one (1) staff room, two (2) bathrooms, a living area, a dining area, a kitchen, and an outside patio area. LPA toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident's personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of the visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. A comfortable temperature was maintained at 73 degrees F. in the facility. LPA observed the facility to be sanitary and appropriately furnished during the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available and maintained adequately. The fire extinguishers were charged, and smoke detectors and carbon monoxide were operable. A review of Medication Records Administration (MAR) was reviewed. The facility has a current liability insurance effective 08/20/25 - 08/20/2026 policy #001209524. Evaluation Report Continues on LIC 809-C During the visit, LPA observed the facility's infection control practices. LPA observed staff followed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). Posters mandated for inspection control were posted. An audit of residents #1-#5 (R1-R5) service records and staff #1-#3 (S1-S3) personnel records. The facility is current on CCL annual dues. Deficiencies: During record reviews of resident files, LPA identified that Residents #2, #3, and #5 did not have a current Medical Assessment LIC 602A. Medication for Resident #1 (Potassium Chloride F10MG), Resident #3 (Morphine & Haloperidol PRN), and Resident #5 (Tamsulosin 0.4MG) were not included in the Medication Administration Log. At 12:10 PM, the hot water temperature was logged at 158.0°F. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiencies has been observed and citation issued (ref. LIC 9099-D). An exit interview conducted with Editha Paclab and a copy of the report is provided. Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) are cleared. * /the state’s words, verbatim · CDSS document, Mar 23, 2026

Type of visit: POC

On March 19, 2025, at 3:30 PM, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced Plan of Corrections visit to the facility following deficiencies noted during the Annual Inspection on February 4, 2025. The LPA met with Editha Paclab, the Administrator, and explained the purpose of the visit. During the inspection on February 4, 2025, the facility received citations for two issues: 87506 missing or incomplete resident records for residents #1 through #5, and 87608 regarding Postural Supports for Resident #3, who is not on hospice care and had full bed rails in place without a physician's order. During the visit, the LPA reviewed all resident files and found that all required Community Care Licensing (CCL) forms were adequately maintained and complete. Additionally, the LPA was presented with an authorized physician's order to use full bed rails for Resident #3. As a result of the audit of resident files, the licensee is now in compliance. No deficiencies cited during this visit. An exit interview conducted with Editha Paclab and a copy of the report is provided.the state’s words, verbatim · CDSS document, Mar 19, 2025

Type of visit: Required - 1 Year

On 02/04/25, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with administrator Editha Pacleb . LPA explained the purpose of today’s visit. The facility is licensed to operate for six (6) non-ambulatory elderly adults ages 60 and above. The facility is approved for one (1) hospice waiver. Currently, there is one hospice resident. The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) residents' rooms, one (1) staff room, two (2) bathrooms, a living area, a dining area, a kitchen, and an outside patio area. LPA toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of the visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. A water temperature of 105.7 degrees F. A comfortable temperature was maintained in the facility. LPA observed the facility to be sanitary and appropriately furnished during the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available and maintained adequately. The fire extinguishers were charged, and smoke detectors and carbon monoxide were operable. A review of Medication Records Administration (MAR) was observed to be maintained in order and accurate. The facility has a current liability insurance effective 08/20/24 - 08/20/25 policy #001209523. Evaluation Report Continues on LIC 809-C During the visit, LPA observed the facility's infection control practices. LPA observed staff followed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). Posters mandated for inspection control were posted. An audit of residents #1-#5 (R1-R5) service records and staff #1-#4 (S1-S4) personnel records. The facility is current on CCL annual dues. The facility has a current Administrator Certificate for Editha A Pacleb 7003753740 valid through 01/31/2024 01/31/2026. Deficiencies: During record reviews of resident files, LPA identified all Resident #1-#5 files were incomplete or mssing. Required CCL forms filled out and no acknowledgement signatures from residents. LPA identified Resident #3 not on hospice care had full bed rails with no physician's order. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiencies has been observed and citation issued (ref. LIC 9099-D). An exit interview conducted with Editha Paclab and a copy of the report is provided. Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) are cleared. *the state’s words, verbatim · CDSS document, Feb 4, 2025

Type of visit: Required - 1 Year

On 03/06/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with administrator Editha Pacleb . LPA explained the purpose of today’s visit. The facility is licensed to operate for six (6) non-ambulatory elderly adults ages 60 and above. The facility is approved for one (1) hospice waiver. Currently, there is one hospice resident. The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) residents' rooms, one (1) staff room, two (2) bathrooms, a living area, a dining area, a kitchen, and an outside patio area. LPA toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of the visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. A water temperature of 105.0 degrees F. A comfortable temperature was maintained in the facility. LPA observed the facility to be sanitary and appropriately furnished during the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available and maintained adequately. The fire extinguishers were charged, and smoke detectors and carbon monoxide were operable. A review of Medication Records Administration (MAR) was observed to be maintained in order and accurate. The facility has a current liability insurance effective 08/20/23 - 08/20/24 policy #001209522. Evaluation Report Continues on LIC 809-C During the visit, LPA observed the facility's infection control practices. LPA observed staff followed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). Posters mandated for inspection control were posted. An audit of residents #1-#5 (R1-R5) service records and staff #1-#4 (S1-S4) personnel records. Interviews conducted with (3) residents. The facility is current on CCL annual dues. The facility has a current Administrator Certificate for Editha A Pacleb #6013416740. Deficiencies: During record reviews of resident files, LPA identified resident #3 with dementia did not have a current medical assessment or appraisal on file. Staff #1-#4 did not have current First Aid/CPR Training on file when staff files were audited. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiencies has been observed and citation issued (ref. LIC 9099-D). An exit interview conducted with Editha Paclab and a copy of the report is provided. Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) are cleared. *the state’s words, verbatim · CDSS document, Mar 6, 2024