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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430703824
Report Date: 09/14/2021
Date Signed: 09/15/2021 10:52:10 AM

Document Has Been Signed on 09/15/2021 10:52 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:PACE - MEADOWSFACILITY NUMBER:
430703824
ADMINISTRATOR:NAWARD HERNANDEZFACILITY TYPE:
735
ADDRESS:862 HOLLENBECK AVENUETELEPHONE:
(408) 835-5503
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY: 6CENSUS: 6DATE:
09/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:10 PM
MET WITH:Naward SmithTIME COMPLETED:
05:20 PM
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Licensing Program Analyst (LPA) Yatfai Eric Ng conducted an unannounced infection control site visit. LPA met with the Clerical Direct Support (CDS) Nancy Moiwa. Later came the Administrator Naward Smith.

One central entry point was designated for all staff, residents, and visitors. A temperature screening station and sign in sheet were present at the entrance. LPA was temperature screened before touring.

LPA toured the facility. All staff were observed to be wearing masks in the facility. There were COVID-19 signs and hand sanitizers at the entrance and in the facility. Hand washing sign was posted in the kitchen to remind the staff to wash their hands before handling food. There was an adequate supply of personal protective equipment in the storage areas. There was a designated visiting area in the backyard for visitors visiting residents.

LPA discussed the infection control with the Administrator and CDS. LPA reviewed the current Provider Information Notice PIN 21-40-ASC with Administrator and made suggestions. All residents and all staff were fully per Administrator .

No deficiency cited during visit.

This report was reviewed with Administrator . A copy of this report were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Yatfai Ng
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2021
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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