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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600821
Report Date: 09/14/2026
Date Signed: 09/14/2026 06:16:15 PM

Document Has Been Signed on 09/14/2026 06:16 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:HOME SWEET HOME SENIOR CAREFACILITY NUMBER:
415600821
ADMINISTRATOR/
DIRECTOR:		IRENA MATIJASFACILITY TYPE:
740
ADDRESS:1560 BRYANT STREETTELEPHONE:
(650) 992-2727
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY: 55CENSUS: 34DATE:
09/14/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:30 PM
MET WITH:Theresa PamintuanTIME VISIT/
INSPECTION COMPLETED:
06:30 PM
NARRATIVE
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Licensing Program Analyst Audrey Jeung met with manager and toured this 2-story facility, consisting of 15 ground floor and 13 second floor client rooms; all rooms have private half bathrooms and some have sliding doors that exit to the walkway or enclosed patio on the ground floor and to private balconies on the second floor. There are Arial emergency call devices in each bedroom and bathroom, so residents can summon staff for assistance. The auditory alert is transmitted to a central monitor at the front reception desk and to each caregivers' handheld device. Random client rooms were inspected, including common areas--TV/activity room, dining room, public restrooms, and 2 shower rooms. There is a front and rear patio, and 9 locked storage cabinets or sheds contain building supplies, decorations, and supplies. No accessible bodies of water or hazards were observed. Smoke detectors and carbon monoxide detectors were observed to be in working condition. Adequate lighting and comfortable indoor temperature were observed in the facility. Emergency exit routes are marked, and an emergency evacuation plan was posted. Carbon monoxide detectors are tested and operable. Food supplies are maintained. Medications are stored in locked medication room. Irene Matijas and Theresa Pamintuan (x 2/27) are certified RCFE administrators that oversee facility operations.

Due to time constraints, client and staff files will be reviewed at a later time.

The following forms are requested to be updated and submitted to CCLD BY 9/28/26:
- Administrative Organization (LIC309)
- Designation of Facility Responsibility (LIC308
- Personnel Report (LIC500)
- Proof of current surety bonding
- Proof of current liability insurance

Deficiencies of the California Code of Regulations, Title 22, are observed and cited on a following page.
April Cowan
Audrey Jeung
DATE: 09/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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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 09/14/2026 06:16 PM - It Cannot Be Edited


Created By: Audrey Jeung On 09/14/2026 at 05:37 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: HOME SWEET HOME SENIOR CARE
FACILITY NUMBER: 415600821

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/15/2026
Section Cited
CCR
87303(e)(2)

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MAINTENANCE AND OPERATIONS
Faucets used by residents for personal care such as shaving and grooming shall deliver hot water..maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F and not more than 120 degree F.
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Hot water temperature shall be lowered and maintained within range of 105 to 120 degrees F. Proof of correction to be sent to CCLD BY DUE DATE.
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This requirement is not met, as hot water temperature tested at 136 degrees F in shower room on ground floor. Licensee failed to maintain hot water temperature within range of 105 to 120 degrees F, which poses an immediate health and safety risk to clients in care.
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Type A
09/15/2026
Section Cited
CCR87608(a)(5)(A)

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POSTURAL SUPPORTS
A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.
This requirement is not met, as half bed rail is placed in the middle of the bed in room 210B. Licensee failed to ensure proper
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Half bed rail shall be repositioned so it is at the head of the bed. Proof of correction to be sent to CCLD BY DUE DATE
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placement of half bed rail, which poses an immediate health, safety or personal rights risk to client in care.
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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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2026


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 09/14/2026 06:16 PM - It Cannot Be Edited


Created By: Audrey Jeung On 09/14/2026 at 05:46 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: HOME SWEET HOME SENIOR CARE
FACILITY NUMBER: 415600821

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/21/2026
Section Cited
CCR
87303(a)

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MAINTENANCE & OPERATION
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met, as delayed
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Delayed egress door shall be repaired to operate efficiently and proof of correction to be sent to CCLD BY DUE DATE.
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egress door near room 177 is not working properly as door opens without delay and without alarm. This door exits to side walkway. Licensee failed to ensure that egress door operates as a delayed egress, which poses a potential health, safety or personel rights risk to clients in care.
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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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2026


LIC809 (FAS) - (06/04)
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