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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430703824
Report Date: 11/21/2022
Date Signed: 11/21/2022 10:19:37 AM

Document Has Been Signed on 11/21/2022 10:19 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
CENTRAL COAST CR/RES, 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: 0DATE:
11/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Aminata KamaraTIME COMPLETED:
10:25 AM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual inspection focusing on infection control. Administrator, Naward Hernandez was not available to meet LPA at the facility and designated Clerical Direct Support, Aminata Kamara to meet with LPA.

During visit, LPA toured the facility to include the living room, kitchen, office, resident bedrooms, bathrooms, garage, and backyard. No residents observed on-site. All fire exit routes were free and clear of obstruction. All staff observed to wear a mask face. All staff present are fingerprint cleared and associated to the facility.

Facility has a designated entry point for temperature check, symptom screening, and sign-in. Staff removed the "no visitors" sign posted at the main entrance. Hand sanitizer made available throughout the facility. LPA observed facility's Personal Protective Equipment (PPE) supplies and lidded trash bin. Bathrooms supplied with paper towels and hygiene products. Facility staff clean and disinfect multiple times daily and as needed. Staff are N95 fit-tested. LPA reviewed facility's procedures to isolation, infection control training, and visitation. The following posters observed to include wear a mask, cough etiquette, stop the spread of germs, hand washing, and symptoms of COVID.

No deficiencies were cited per California Code of Regulations, Title 22. Advisory notes provided.

This report was reviewed with Aminata Kamara and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2022
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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