StarlynnCare

California · San Bruno

Pacaldo Llc

RCFE · Memory Care

A Residential Care Facility for the Elderly (RCFE) is a non-medical residential care home licensed by California CDSS under Health & Safety Code §1560. Residents receive help with daily living activities such as bathing, dressing, and medication management. An RCFE with a Memory Care designation is additionally required by California Title 22 (§87705 and §87706) to provide specialized staff training in dementia care, individualized care plans for residents with cognitive impairment, and appropriate supervision protocols — requirements that go beyond a standard RCFE license.

2735 Fleetwood Drive · San Bruno, 94066

Quick facts

Licensed beds6
Memory careYes
Last inspectionMay 2025
Last citationMay 2025
Operated byPacaldo Llc
Map showing location of Pacaldo Llc

Quality snapshot

Updated April 26, 2026

Compared to 182 California RCFE memory care facilities of similar size, over the last 36 months.

Source: California Department of Social Services, Community Care Licensing Division. View raw inspection records →

Quality grade· click to show how this was calculated

Severity
35th

Weighted citations per bed

Repeats
100th

Repeat deficiencies as share of total

Frequency
48th

Deficiencies per inspection

Tick mark at 50% = peer median · higher percentile = better facility

Pacaldo Llc scores B−. Better than 61% of comparable California RESIDENTIAL CARE ELDERLY facilities. Severity: 35th percentile. Repeats: top 0%. Frequency: 48th percentile.

Each metric is converted to a 0–100 percentile within the peer set (higher = better). The composite grade averages all four. Peer set: CA / rcfe_memory_care / small beds (182 facilities).

Citation severity over time

↓ improving

Weighted severity score per month · 24 months

May 24peer medianApr 26

Weighted score (24mo)

59

Last citation

May 25

Finding distribution

8 total · 36 months

Scope × Severity (CMS A–L)

IsolatedPatternWidespreadJKLG5HID3EFABCSev 4 · IJSev 3Sev 2Sev 1

View inspections & citations

The rules that apply to this facility

California Title 22 requirements for this facility, with the specific regulation and a suggested question for each.Rules this facility has been cited for are shown first.

What dementia-care training must staff complete?Cited May 202422 CCR §87705 / HSC §1569.625

Because this facility markets dementia or Alzheimer's care, state law mandates higher training standards:

  • 12 hours initial dementia training — 6 hours before a staff member works independently with residents, 6 more within the first 4 weeks.
  • 8 hours annual dementia in-service — required every year thereafter.
  • Administrator CE — the administrator must include 8 hours of dementia-specific continuing education in every 2-year recertification cycle.

Training must cover individualized care plans, behavioral expressions, appropriate supervision, and the facility's dementia care philosophy.

Ask on tour: Ask how dementia training records are kept — families may request documentation.

How many staff must be on duty overnight?22 CCR §87415

Based on 6 licensed beds:

One qualified staff member must be on call and physically on premises at all times overnight.

Violation pattern to watch for:A facility that documents a staff member as "on call" but with that person physically off-site — when the law requires on-premises presence — is in violation of this section.

Ask on tour: Ask the facility to walk you through their overnight staffing plan and confirm whether on-call staff are on premises or off-site.

What health conditions can this facility legally accept or refuse?22 CCR §87612–87615

Restricted — allowed with physician order + care plan

  • Supplemental oxygen
  • Insulin and injectable medications
  • Indwelling or intermittent catheters
  • Colostomy / ileostomy
  • Stage 1 and Stage 2 pressure injuries
  • Wound care (non-complex)
  • Incontinence
  • Contractures

Prohibited — facility must refuse or discharge

  • Stage 3 or Stage 4 pressure injuries
  • Feeding tubes (PEG, NG, or J-tube)
  • Tracheostomies
  • Active MRSA or communicable infections requiring isolation
  • 24-hour skilled nursing needs
  • Total ADL dependence with inability to communicate needs

A hospice waiver (HSC §1569.73) can allow continued care for residents on hospice who would otherwise fall into a prohibited category.

Ask on tour: Ask whether your loved one's specific care needs are restricted or prohibited, and what the facility's process is if needs change after admission.

What must this facility report to the state — and how fast?22 CCR §87211 / WIC §15630
  • ImmediateElopement, fire, epidemic outbreak, or poisoningImmediately
  • 2 hoursAbuse with serious bodily injury2-hour phone report + 2-hour written report — to the California Department of Social Services (CDSS), Adult Protective Services, and law enforcement
  • 24 hrsAbuse without serious bodily injuryWithin 24 hours
  • Next dayDeath of a residentPhone by next working day; written within 7 days
  • Next dayInjury requiring medical treatment beyond first aidPhone by next working day; written within 7 days
  • WrittenBankruptcy, foreclosure, eviction, or utility shutoff noticeWritten notice to CDSS and residents — $100/day penalty (max $2,000) for failure

Your enforcement lever:Incidents that aren't reported on time are themselves a separate violation. If you believe a reportable event wasn't filed, you can submit a complaint directly to the California Department of Social Services (CDSS).

How does CDSS enforce these rules?22 CCR §87755–87777 / HSC §1569.58
  1. 1Notice of DeficiencyWritten citation with a correction deadline. Facility must submit a Plan of Correction.
  2. 2Civil PenaltyStarts at $50/day for non-serious; $150/day for serious deficiencies — immediately, with no grace period. Repeats escalate to $150 first day + $50/day, then $1,000 first day + $100/day.
  3. 3Suspension of AdmissionsFacility cannot accept new residents until violations are corrected.
  4. 4Temporary Suspension or RevocationEmergency suspension for imminent danger; full revocation after administrative hearing.
  5. 5Exclusion OrderAdministrator and operator can be barred from all CDSS-licensed facilities — not just this one.

See how these rules have been applied to this specific facility:

View state inspection record and citations

State records

California Dept. of Social Services · Community Care Licensing
License number
415601078
License type
RESIDENTIAL CARE ELDERLY
License status
LICENSED
License expires
Not yet indexed
Licensed beds
6
Operator
Pacaldo Llc

Inspections & citations

4

reports on file

8

total deficiencies

5

Type A (actual harm)

1

dementia-care citations

Other visitMay 28, 2025Type A
3 deficiencies

Plain-language summary

During an unannounced annual inspection on May 28, 2025, inspectors found the facility's living areas, bathrooms, and safety features to be in good condition, with sufficient food, linens, and supplies. However, inspectors identified violations related to storage safety: a locked cabinet containing sharps and chemicals was left accessible to residents, and medication was found unlocked on the dining room table where residents could access it. The facility has been notified of these violations and given an opportunity to correct them.

View full inspector notes

On May 28, 2025 Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. LPA met with caregiver, Maria Razon and explained the purpose of the visit. The administrator, Oscar Madrigal arrived shortly thereafter and assisted with the inspection. LPA toured the facility inside out and inspected the living room, dining area, kitchen, bedrooms, bathrooms, and backyard. The indoor and outdoor passageways were free of obstruction. The facility has 4 resident rooms (two shared and 2 private room) and 1 staff room. Furniture and furnishings were observed to be sufficient. Food supplies were sufficient of 2- days perishables and 7- days of non-perishables. Toilet, hand washing and bathing areas were observed clean and in operating condition. Showers were observed equipped with non-skid mats and grab bars. Facility exits are equipped with audible alarms. Comfortable temperature is maintained and lighting is sufficient for comfort Bed sheets, linens, and towels were observed to be sufficient and able to meet the needs of the residents at this time. Central storage for sharps and chemicals were observed to be unlocked and accessible to residents in care. LPA observed medication on the dining room table, unlocked and accessible to residents. Hot water temperature in the kitchen and bathroom were measured at 105-111 degrees Fahrenheit. Fire extinguishers were checked and last inspected on 1/21/2025. 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. 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.

Type ACCR §87618(b)(3)(E)

Regulation

(3) Ensuring that the use of oxygen equipment meets the following requirements: (E) Oxygen tanks that are not portable shall be secured in a stand or to the wall.

Inspector finding

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed R3 has a portable oxygen tank in the room that was not secured in a stand or to the wall which poses an immediate health, safety or personal rights risk to persons in care. POC Due Date: 05/29/2025 Plan of Correction 1 2 3 4 The administrator will develop a plan to ensure portable oxygen tank are properly secured and will provide a photo(s) to proof that R3's oxygen ta…

Type BCCR §87618(b)(3)(A)

Regulation

(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.

Inspector finding

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed R2 and R3 have oxygen and the facility was not able to provide proof that the local fire jurisdiction was notified which poses/posed a potential health, safety or personal rights risk to persons in care. POC Due Date: 06/05/2025 Plan of Correction 1 2 3 4 The administrator will develop a plan to ensure the local fire department is notified with residents who are on oxy…

Type ACCR §87565(h)(1)(2)

Inspector finding

87465 Incidental Medical and Dental Care Deficient Practice Statement 1 2 3 4 Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed R5 was sitting in the dining room and R3's prescribed cream was placed on the dining room table in front of R5 which poses an immediate health, safety or personal rights risk to persons in care. POC Due Date: 05/29/2025 Plan of Correction 1 2 3 4 The administrator will develop a plan to ensu…

InspectionAugust 21, 2024
No deficiencies

Inspector: Murial Han

Plain-language summary

During an August 2024 follow-up visit, the state investigated a report that a resident was sexually abused by a staff member after disclosing this to hospital staff in February 2024. After interviewing staff, other residents, and the resident's family, the state found no evidence to support the allegation and determined the report was unsubstantiated. No violation was cited.

View full inspector notes

On August 21, 2024, Licensing Program Analyst (LPA), Murial Han conducted an unannounced Case Management visit to deliver the findings of an incident that was reported by the facility. LPA met with caregiver, Wilfredo Monoy and explained the purpose to today's visit. On February 14, 2024, facility reported resident #1 (R1) was hospitalized due to a change of health condition and on the day of the discharge, R1 verbalized to the hospital staff that he/she was sexually abused by staff #1 (S1). As part of the investigation, the Department interviewed staff members, residents and R1's responsible party. The facility staff stated that they have not witnessed any suspicious or inappropriate behavior involving S1 toward R1 or other residents; other residents reported that they feel safe at the facility and R1's responsible party reported that R1 was not a reliable historian. After the investigation, this incident is deemed to be unsubstantiated. No deficiency is being cited today. This report is reviewed and discussed with caregiver and a copy if provided.

Other visitMay 8, 2024Type A
5 deficiencies

Inspector: Murial Han

Plain-language summary

This was a routine annual inspection conducted in May 2024 at an unannounced visit. The facility passed most requirements, with adequate space, clean bathrooms, working safety features like grab bars and exit alarms, and sufficient food and supplies on hand. However, the facility was cited for a deficiency: medication, sharp, and chemical storage areas were found unlocked and accessible to residents, which poses a safety risk.

View full inspector notes

On May 8, 2024 Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. LPA met with caregiver, Maria Razon and explained the purpose of the visit. The administrator, Oscar Madrigal arrived shortly thereafter and assisted with the rest of the inspection. LPA toured the facility inside out and inspected the living room, dining area, kitchen, bedrooms, bathrooms, and backyard. The indoor and outdoor passageways were free of obstruction. The facility has 4 resident rooms (two shared and 2 private room) and 1 staff room. Furniture and furnishings were observed to be sufficient. Food supplies were sufficient of 2- days perishables and 7- days of non-perishables. Toilet, hand washing and bathing areas were observed clean and in operating condition. Showers were observed equipped with non-skid mats and grab bars. Facility exits are equipped with audible alarms. Comfortable temperature is maintained and lighting is sufficient for comfort Bed sheets, linens, and towels were observed to be sufficient and able to meet the needs of the residents at this time. Central storage for medications, sharps and chemicals were observed to be unlocked and accessible to residents in care. Hot water temperature in the kitchen and bathroom were measured at 105-112 degrees Fahrenheit. Fire extinguishers were checked and last inspected on 4/2/2024. 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. The following documents were requested submitted to CCL by 5/9/24: - liability insurance 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.

Type ACCR §87705(f)(1)

Regulation

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

Inspector finding

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed sharps, chemicals and medications are not locked and accessible to resident in care which poses an immediate health, safety or personal rights risk to persons in care. POC Due Date: 05/09/2024 Plan of Correction 1 2 3 4 The administrator/licensee will develop a plan to ensure this does not happen again and will provide in-services to staff. The administrator/licensee w…

Type ACCR §87412(a)(12)

Regulation

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) Hazardous health conditions documents as specified in Section 87411, Personnel Requirements - General.

Inspector finding

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 2 out of 2 facility staff did not have TB screening documentation in their personnel file which poses an immediate health, safety or personal rights risk to persons in care. POC Due Date: 05/09/2024 Plan of Correction 1 2 3 4 The administrator/licensee will develop a plan to ensure this does not happen again and provide a copy of the signed and dated plan to CCL by 5/9/2024 and a …

Type A

Regulation

(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,…

Inspector finding

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as the facility was not able to provide proof that emergency drills were conducted which poses an immediate health, safety or personal rights risk to persons in care. POC Due Date: 05/09/2024 Plan of Correction 1 2 3 4 The administrator/licensee will develop a plan to ensure drills are conducted accordingly and will provide a copy of the signed and dated plan to CCL by 5/9/2024.

Type BCCR §87355(j)

Regulation

(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.

Inspector finding

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 1 out of 2 staff did not have criminal record clearances in the personnel file which poses/posed a potential health, safety or personal rights risk to persons in care. POC Due Date: 05/13/2024 Plan of Correction 1 2 3 4 The administrator/licensee will develop a plan to ensure this does not happen again and provide a copy of the signed and dated plan to CCL by 5/13/2024. In addition…

Type BCCR §87411(c)(6)

Regulation

(6) The licensee shall maintain documentation pertaining to staff training in the personnel records, as specified in Section 87412(c)(2). For on-the-job training, documentation shall consist of a statement or notation, made by the trainer, of the content covered in the training. Each item of documentation shall include a notation that indicates whi…

Inspector finding

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 2 out of 2 staff did not have documentation in the personnel files to proof that staff training was completed which poses/posed a potential health, safety or personal rights risk to persons in care. POC Due Date: 05/13/2024 Plan of Correction 1 2 3 4 The administrator/licensee will develop a plan to ensure this does not happen again and provide a copy of the signed and dated plan t…

InspectionFebruary 21, 2024
No deficiencies

Inspector: Murial Han

Plain-language summary

On February 21, 2024, inspectors conducted an unannounced visit after the facility reported that a resident had been hospitalized and later alleged sexual abuse by a staff member. The facility began an investigation immediately upon learning of the allegation, implemented safety measures, and the resident returned to the facility with no further concerns reported. Inspectors found no violations during the visit and observed the facility to be clean with residents calm and comfortable.

View full inspector notes

On February 21, 2024, Licensing Program Analyst (LPA) Murial Han conducted an unannounced Case Management Health Checks visit due to an incident that was reported by the facility on February 14, 2024. LPA met with caregiver, Wilfredo Monoy and explained the purpose of the visit. The administrator, Oscar Madrigal arrived shortly thereafter and assisted with the rest of the visit. On February 14, 2024, facility reported that resident #1(R1) had a change of health condition and was transferred to the hospital. On the day of R1's discharge, the facility was notified by the hospital that R1 alleged sexual abused by staff #1 (S1). During today's visit, LPA toured the facility with caregiver observed facility to be cleaned and tidy and residents to be calm and comfortable. LPA spoke to residents, staff and administrator. According to the administrator, when the facility was notified of the incident, the facility started to investigate and implemented interventions to ensure the safety of the resident. According to the residents, they are doing well and staff members are providing the care that they need. The administrator also reported that R1 has returned to the facility with no further concerns. No deficiency cited today. This report is reviewed and discussed with the administrator; A copy is provided.

Federal summary

CMS Care Compare

Not a CMS-certified facility

California RCFEs (residential care facilities for the elderly) are licensed by the state, not by CMS. CMS data only applies to skilled nursing facilities or to CCRCs that operate a licensed SNF wing.

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