Health conditions and treatments
Cited in 2 reports, with 3 deficiencies in total.
PACIFIC CARE HOME III
2880 ST. CLOUD DRIVE, San Bruno CA 94066
6 bedsLatest official report Mar 3, 2026Licensed
Additional info
- Telephone
- (650) 615-9071
- Licensee
- J & I LLC
- Administrator
- ICK, WILHELM O.
- Contact
- ICK, WILHELM O.
- License first date
- Apr 28, 2015
- License effective date
- Apr 28, 2015
- District office
- SAN BRUNO RO · (650) 266-8800
- Regional office
- 14
- Clients served
- 985 - RCFE / HOSPICE
Summary
The available records show 9 Type A and 5 Type B deficiencies for this facility.
- Most recent inspection
- Mar 3, 2026
- Most recent deficiency
- Mar 3, 2026
No later report is available, so the records do not show what happened afterward.
What Type A and Type B mean
- Type A
- 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
- Violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care.
Both classifications are published by California CDSS and are shown as published. SeniorLivingFacts does not rename them or add a severity level of its own.
At a glance
Counts cover the five-year public record. Typical figures are the median for the 150 San Mateo County facilities licensed for 6 or fewer beds.
In the available public five-year record, CCLD published 4 reports for this facility: 4 inspections, 0 complaint investigations, and 0 licensing or administrative records.
Those records contain 9 Type A and 5 Type B deficiencies.
0 deficiencies have explicit official correction or clearance evidence in the loaded records.
- Official inspections
- 4
- Recorded deficiencies
- 14
- Type A deficiencies
- 9
- Type B deficiencies
- 5
- Substantiated complaints
- 0
- Repeated topics
- 4
About the same as most this size
1 in the last 12 months
Well above the typical 4
5 in the last 12 months
Well above the typical 1
3 in the last 12 months
More than the typical 2
2 in the last 12 months
Most this size also have none
0 in the last 12 months
Last 36 months
Repeated topics
Topics cited in more than one report during the last 36 months. A repeat may show a pattern worth asking about. Each date opens its report below.
Facility condition and maintenance
Cited in 2 reports, with 2 deficiencies in total.
Hazardous items and storage
Cited in 2 reports, with 2 deficiencies in total.
Licensing and administration
Cited in 2 reports, with 2 deficiencies in total.
Official report history
All preserved reports from the most recent to the oldest, sortable by report type.
Inspection
Medication handling and storageType A
- Official classification
- Type A
- Official code
- 87465(h)(5)
- Regulation authority
- CCR
What the official deficiency says
(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 Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA and IB investigator observed medication was removed from its original container which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 03/04/2026 Plan of Correction The administrator will remove the pill organizers and re-educate staff to not remove medication from its original container to administer the medication for later shifts. The administrator will provide a copy of the sign and date plan of correction to CCL by 3/4/2026.
Plan of correction recorded
Correction not verified in available records
Medical and dental careType A
- Official classification
- Type A
- Official code
- 87465(e)
- Regulation authority
- CCR
What the official deficiency says
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA and IB investigator observed an over the counter Blink Eye Drop in R2's room without a physician's order which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 03/04/2026 Plan of Correction The Blink Eye Drop was removed immediately. The administrator will develop a plan of correction to ensure all medications are prescribed and centrally stored. The plan of correction shall include staff re-education. The administrator will submit the signed and dated plan of correction to CCL by 3/4/2026.
Plan of correction recorded
Correction not verified in available records
Health conditions and treatmentsType A
- Official classification
- Type A
- Official code
- 87608(a)(5)(B)
- Regulation authority
- CCR
What the official deficiency says
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA and IB investigator observed R3 has full bedrails which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 03/04/2026 Plan of Correction The administrator will change the full rails to half rails with physician's order. The administrator will provide a plan of correction to ensure compliance and re-educate staff members. The administrator will provide a copy of the signed and dated POC to CCL by 3/4/2026.
Plan of correction recorded
Correction not verified in available records
Medical and dental careType B
- Official classification
- Type B
- Official code
- 87465(a)(6)
- Regulation authority
- CCR
What the official deficiency says
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above LPA and IB investigator observed R2, R3 and R4's centrally stored medication records were incomplete and medication was not logged which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 03/13/2026 Plan of Correction The administrator will provided updated centrally stored medication records to residents identified and a plan to ensure compliance with staff re-education. The administrator will provide a copy of the plan of correction to CCL by 3/13/2026.
Plan of correction recorded
Correction not verified in available records
Facility condition and maintenanceType B
- Official classification
- Type B
- Official code
- 87307(a)
- Regulation authority
- CCR
What the official deficiency says
87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, This requirement is not met as evidenced by: LPA and IB investigator observed clothing, Rosary, futon bed, medication, comb, shoes in the garage. Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA and IB investigator observed clothing, Rosary, futon bed, medication, comb, shoes in the garage which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 03/17/2026 Plan of Correction The administrator will develop a plan to ensure residents and staff are provided with a comfortable living space. The administrator will submit a copy of the plan of correction to CCL by 3/17/2026.
Plan of correction recorded
Correction not verified in available records
Inspection
Health conditions and treatmentsType B
- Official classification
- Type B
- Official code
- 87618(b)(3)(A)
- Regulation authority
- CCR
What the official deficiency says
(3) Ensuring that the use of oxygen equipment meets the following requirements: (A) A report shall be made in writing to the local fire jurisdiction that oxygen is in use at the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as R1, R2 and R3 have oxygen and there is no proof that a report has been made to the local fire jurisdiction which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 04/09/2025 Plan of Correction The administrator will develop a plan to ensure compliance and will provide a copy of the plan to CCL 4/9/2025. In addition, A copy of the proof that the report was sent to the local fire jurisdiction.
Plan of correction recorded
Correction not verified in available records
Health conditions and treatmentsType B
- Official classification
- Type B
- Official code
- 87633(a)(2)
- Regulation authority
- CCR
What the official deficiency says
(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility, when all of the following conditions are met: (2) The licensee remains in substantial compliance with the requirements of this section, with the provisions of the Residential Care Facilities for the Elderly Act (Health and Safety Code Section 1569 et seq.), all other requirements of Chapter 8 of Title 22 of the California Code of Regulations governing Residential Care Facilities for the Elderly, and with all terms and conditions of the waiver. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as the facility has an approved hospice waiver for 2 but currently has 3 residents who are on hospice which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 04/09/2025 Plan of Correction The administrator shall develop a plan to ensure compliance and will provide a copy of the plan to CCL by 4/9/2025.
Plan of correction recorded
Correction not verified in available records
Inspection
Facility condition and maintenanceType A
- Official classification
- Type A
- Official code
- 87305(a)
- Regulation authority
- CCR
What the official deficiency says
Prior to construction or alterations, all facilities shall obtain a building permit. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed garage has livable items such as toiletries, futon beds, personal hygiene items, clothing, shoes, etc. which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 04/24/2024 Plan of Correction The administrator/licensee shall remove furniture, and personal items in the garage and provide photos to CCL by 4/24/2024 to ensure safety for residents and facility staff.
Citation dismissed - not a correction
Deficiency Dismissed Type A Section Cited CCR 87305(a)
Plan of correction recorded
Correction not verified in available records
Hazardous items and storageType A
- Official classification
- Type A
- Official code
- 87309(a)
- Regulation authority
- CCR
What the official deficiency says
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed chemicals in the kitchen area and in the garage are unlocked and accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 04/24/2024 Plan of Correction The administrator/licensee shall develop a plan to ensure compliance and send photos to CCL by 4/24/2024 to ensure all chemicals are locked and inaccessible to residents in care.
Plan of correction recorded
Correction not verified in available records
Fire safety and emergency preparednessType A
- Official classification
- Type A
- Official code
- 1569.695(c)
- Regulation authority
- HSC
What the official deficiency says
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as facility was not able to provide documents that emergency drill were conducted which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 04/24/2024 Plan of Correction The administrator/licensee shall develop a plan to ensure drills are conducted accordingly and the plan shall include staff training. The administrator/licensee will provide a copy of the plan to CCL by 4/24/2024.
Plan of correction recorded
Correction not verified in available records
Licensing and administrationType B
- Official classification
- Type B
- Official code
- 87755(c)
- Regulation authority
- CCR
What the official deficiency says
This requirement is not met as evidenced by: 87755 Inspection Authority of the Licensing Agency Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 1 out of 3 staff personnel file was not available for review during the inspection which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 04/29/2024 Plan of Correction The administrator/licensee will develop a plan to ensure staff files are available to inspect and provide a copy of the plan to CCL by 4/29/2024
Plan of correction recorded
Correction not verified in available records
Inspection
Hazardous items and storageType A
- Official classification
- Type A
- Official code
- 87309(a)
- Regulation authority
- CCR
What the official deficiency says
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation while touring this facility, the licensee did not comply with the section cited above in that cleaning solutions, detergents, and cleaning supplies were found to be under restrooms sinks, kitchen sink, and the garage area where they were not secured and made accessible to the residents which posed an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 10/15/2023 Plan of Correction The facility designated Administrator stated that all cleaning solutions, detergents, and cleaning supplies will always be stored and made inaccessible to the residents at all times. All cleaning supplies will be removed and relocated to storage areas which will be properly locked and made inaccessible to the residents in care. A statement of correction, along with pictures of newly installed locks on the garage doors, will be completed and submitted into CCL by the due date.
Plan of correction recorded
Correction not verified in available records
Licensing and administrationType A
- Official classification
- Type A
- Official code
- 1569.618(c)(3)
- Regulation authority
- HSC
What the official deficiency says
(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in [1] out of [5] facility personnel files did not have updated, and certified, first aid training which posed an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 10/21/2023 Plan of Correction The facility designated Administrator stated that all staff providing care and supervision to the residents will be trained in First Aid. A statement of correction will be completed, along with copies of completed updated First Aid training, will be submitted into CCL by the due date.
Plan of correction recorded
Correction not verified in available records
Dementia careType A
- Official classification
- Type A
- Official code
- 87705(c)(5)
- Regulation authority
- CCR
What the official deficiency says
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in that [3] out of [5] residents diagnosed with dementia did not have a required updated annual medical assessment which posed an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 10/21/2023 Plan of Correction The facility designated Administrator stated that all residents diagnosed with dementia will be scheduled, with their respective licensed medical professionals, to be reappraised to address any changes, if any, to their care needs. A statement of correction, along with copies of updated medical assessments for dementia diagnosed residents, to be completed and submitted into CCL by the due date.
Plan of correction recorded
Correction not verified in available records
Source and limits
California Department of Social Services, Community Care Licensing Division. Public facility history is described by the source as a five-year window. Older records and previous-licensee history may require a regional-office request. Type 741 RCFE-CCRCs, nursing homes, and other care settings are excluded from this page.
Read the data methodology