430703824-4-17-2024-26-AS-JJIN-D7FUQV-20240723154747

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 430703824
Report Date: 04/17/2024
Date Signed: 04/17/2024 03:05:30 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/09/2024 and conducted by Evaluator Christine Dolores

COMPLAINT CONTROL NUMBER: 26-AS-20240409154903

FACILITY NAME:	PACE - MEADOWS		FACILITY NUMBER:	430703824
ADMINISTRATOR:	NAWARD HERNANDEZ		FACILITY TYPE:	735
ADDRESS:	862 HOLLENBECK AVENUE		TELEPHONE:	(408) 835-5503
CITY:	SUNNYVALE	STATE: CA	ZIP CODE:	94087
CAPACITY:	6	CENSUS: 5	DATE:	04/17/2024
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Naward Hernandez		TIME COMPLETED:	03:10 PM

ALLEGATION(S):

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Facility locks the residents food

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to open the initial complaint investigation. LPA met with Administrator, Naward Hernandez and Direct Support Staff (DSP), Henry Akapo.

On 04/09/2024, the Department received a complaint alleging the facility locks the residents food in the kitchen area. On 04/17/2024, the initial complaint investigation was conducted.

During visit, LPA was unable to obtain copies of documents due to a printer error. Administrator will email the requested documents to LPA Dolores before end of day to include: Resident Roster, R1 - R5's physician's report, appraisal/needs and services plan, IPP, and recent behavior support plan. SEE LIC9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20240409154903

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: PACE - MEADOWS	FACILITY NUMBER: 430703824
	VISIT DATE: 04/17/2024

NARRATIVE

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LPA entered the facility's kitchen area and observed the kitchen refrigerator and freezer. Based on observation, the refrigerator/freezer contained a child safety strap lock that was not in use. LPA observed the freezer contained the child safety strap that was only half way snapped in place. LPA observed the freezer was able to open. Staff demonstrated that the child safety strap lock on the freezer is broken. LPA did not observe the safety strap on the refrigerator. Photographs were obtained using LPAs state provided phone.

LPA entered into the laundry room area and observed 1 large freezer and 1 refrigerator/freezer appliance which did not contain locks.

Based on interviews, 4 out of 4 staff denied locking the refrigerator and freezer this year. During interviews, it was stated that they had used the locking device last year because they had a resident who had safety concerns with food. The Administrator stated that last year the facility was informed by Licensing that they cannot utilize the locks, and after that visit with Licensing, the facility did not utilize the locking device on the refrigerator/freezer.
Based on observation, LPA observed 2 out of 5 residents request for snacks through gesture and verbally. LPA observed the staff provide the residents snacks to include ice cream, chips, and drinks. LPA observed a resident was freely able to open the refrigerator to grab his/her own item.

5 out of 5 resident records were reviewed. Based on record review, 2 out of 5 residents has a special diet. 2 out of 5 residents special diet did not state a safety concern with accessibility to food which would require the refrigerator/freezer to be locked.

During visit, staff removed the locking device completely from the kitchen refrigerator/freezer.

The Department has investigated the above allegation. Based on interview, record review and observed the above allegation is unsubstantiated. An unsubstantiated finding indicates that although the allegation may have happened and/or is valid there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Direct Support Staff (DSP), Henry Akapo and a copy of the report was provided.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024

LIC9099 (FAS) - (06/04)

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