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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430703824
Report Date: 12/28/2023
Date Signed: 12/28/2023 04:29:09 PM

Document Has Been Signed on 12/28/2023 04:29 PM - 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: 5DATE:
12/28/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Naward HernandezTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Administrator Naward Hernandez. The purpose of the visit was to follow up with a Death Report submitted by the facility on 09/27/2023. The Death Report was for resident R1, who choked on a croissant in the facility on 09/13/2023. R1 was sent to the hospital, where R1 became deceased on 09/26/2023.

During visit, LPA Marrufo obtained copies of the following documents: R1's Physician's Report, Appraisal/Needs and Services Plan, and Individual Program Plan.

R1's Physician's Report states R1 did not have a special diet and was able to feed self. R1's Appraisal/Needs and Services Plan does not mention R1's feeding needs and capabilities. R1's Individual Program Plan states R1 is able to feed self with a fork and spoon without spilling.

No deficiencies were cited at this time as per California Code of Regulations Title 22.

This report was reviewed with Administrator Nawada Hernandez and a copy of this report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/28/2023
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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