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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601180
Report Date: 09/22/2026
Date Signed: 09/22/2026 01:41:27 PM

Document Has Been Signed on 09/22/2026 01:41 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:PECH5 MG OC LLCFACILITY NUMBER:
415601180
ADMINISTRATOR/
DIRECTOR:		VERMA, NEERUFACILITY TYPE:
740
ADDRESS:800 ROBLE AVENUETELEPHONE:
(408) 807-1984
CITY:MENLO PARKSTATE: CAZIP CODE:
94025
CAPACITY: 45CENSUS: 28DATE:
09/22/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Administrator Designee, Jizzel ClementTIME VISIT/
INSPECTION COMPLETED:
01:55 PM
NARRATIVE
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On September 22, 2026 Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. Upon entry, LPA met with Administrator Designee, Jizzel Clement and LPA explained the purpose of today's visit. The Quality Assurance, Jennifer Tobias arrived and assisted with the inspection.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a memory care facility with 1st floor resident care and some office space, bathroom and staff breakroom on the 2nd floor. LPA toured the facility resident rooms, common areas, communal bathrooms, and supply room. LPA observed residents participating in activities. A comfortable temperature is maintained in the facility and lighting is sufficient for comfort. Hot water temperature measured between 106-108 degrees F throughout the facility. Overall facility was in clean, odor-free and free from any tripping hazards. Resident rooms and bathrooms observed had all required furnishings, and grab bars.

LPA toured the kitchen and observed 2 days for perishables and 7 days non-perishable.

During the tour of the medication room, LPA observed some medications were removed from its original container and placed into a plastic medicine cup. According to the med tech and the administrator designee, those were as needed medications and they were prepared last night. They also stated that they were not administered because the residents did not need them.

LPA observed sharps and chemicals were locked and inaccessible to residents.



LPA reviewed the emergency drill records to be adequate.
April Cowan
Murial Han
DATE: 09/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2026
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 5
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: PECH5 MG OC LLC
FACILITY NUMBER: 415601180
VISIT DATE: 09/22/2026
NARRATIVE
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A review of (5) resident files was conducted and noted on LIC 858.

A review of (5) staff files was conducted and noted on LIC 859.

Based on observation, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties.



This report is reviewed and discussed with administrator. A copy of this report and the appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Murial Han
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2026
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 09/22/2026 01:41 PM - It Cannot Be Edited


Created By: Murial Han On 09/22/2026 at 01:32 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: PECH5 MG OC LLC
FACILITY NUMBER: 415601180

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above During the tour of the medication room, LPA observed some medications were removed from its original container and placed into a plastic medicine cup. According to the med tech and the administrator designee, those were as needed medications and they were prepared last night. They also stated that they were not administered because the residents did not need them which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/23/2026
Plan of Correction
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The administrator will develop a plan of correction to ensure no medications shall be transferred between containers. The plan shall include staff training. The administrator will submit a copy of the POC to CCL by 9/23/2026.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:
Murial Han
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/22/2026 01:41 PM - It Cannot Be Edited


Created By: Murial Han On 09/22/2026 at 01:32 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: PECH5 MG OC LLC
FACILITY NUMBER: 415601180

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87355(j)
Criminal Record Clearance
(j) The licensee shall maintain documentation of criminal record clearances or criminal record exemptions of employees in the individual's personnel file as required in Section 87412, Personnel Records.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above LPA observed S1 did not have documentation of the criminal record clearance in their personnel records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2026
Plan of Correction
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The administrator will submit a plan of correction to ensure compliance and will submit a copy of the plan to CCL by 9/29/2026.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:
Murial Han
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2026


LIC809 (FAS) - (06/04)
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