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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200320
Report Date: 07/22/2022
Date Signed: 07/22/2022 03:57:31 PM

Document Has Been Signed on 07/22/2022 03:57 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:PACE - MAHALOFACILITY NUMBER:
435200320
ADMINISTRATOR:AIDA URENAFACILITY TYPE:
735
ADDRESS:1720 MERRILL DRIVETELEPHONE:
(408) 475-3015
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY: 6CENSUS: 5DATE:
07/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:51 AM
MET WITH:AIDA URENATIME COMPLETED:
01:32 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) Aida Urena. Upon arrival, staff Violet Duarte (VD) took LPA body temperature, asked the infection control questionnaires, and checked LPA in the visitor log book.

LPA toured the facility inside out with ADM. COVID posters were observed at main entrance and the facility. Screening station with masks, hand sanitizer, thermometer and visitor log book was observed at the main entrance. Living room, family room, kitchen, dinning room and two restrooms were inspected. All trash cans were observed with covers. Paper towels in restrooms were observed without holder. No poster of washing hand for 20 seconds was observed by the sink in restrooms. ADM stated the facility will put the paper towel with holder in 3 days. ADM stated the facility will put the posters of washing hand for 20 seconds by the sink in restrooms in 3 days. Cloth towels were observed in kitchen. Three single resident bedrooms, one shared bedroom, and laundry room were inspected. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. PPE supplies were observed sufficient. Medication closet, knives closet, and cleaning product closet were observed locked. Room temperature was at 71 degree F, and hot water temperature was at 108 degree F in facility. 3 residents and 2 staff were observed in facility.

Fire extinguisher was serviced on 09/09/2021. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways.

No citation was noted today. Exit interview was conducted with ADM. This report was provided to ADM for signature.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2022
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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