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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430703824
Report Date: 10/14/2024
Date Signed: 10/14/2024 01:40:48 PM

Document Has Been Signed on 10/14/2024 01:40 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/
DIRECTOR:		NAWARD HERNANDEZFACILITY TYPE:
735
ADDRESS:862 HOLLENBECK AVENUETELEPHONE:
(408) 835-5503
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY: 6CENSUS: 4DATE:
10/14/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Aminata Kamara and Naward HernandezTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On October 14, 2024, Licensing Program Analyst (LPA) Kiran Jain conducted an unannounced Plan of Correction (POC) visit to verify and confirm that the facility is in compliance with the citations issued during the annual inspection on October 3, 2024. LPA met with Aminata Kamara, DSP, and explained the purpose of the visit. Naward Hernandez, Administrator joined shortly after.

On 10/03/2024, the facility was cited for two deficiencies under the California Code of Regulation (CCR), 80087(g) Building and Grounds, and 80087(c) Building and Grounds.

During the visit, LPA observed that the disinfectant, bleach, and other cleaning solutions were properly locked/stored in a cabinet in the garage, and inaccessible to residents in care. The deficiency for CCR 80087(g) is corrected and the citation is cleared.

The facility still has an outstanding Plan of Correction for the 80087(c) Building and Grounds deficiency, which is due by 10/18/2024. The Administrator, Naward Hernandez, has agreed to submit a proof of correction via email, including photographic evidence.

No deficiencies were cited during the visit. The report is reviewed with Naward Hernandez, Administrator , and a copy is provided.

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2024
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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