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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200320
Report Date: 07/16/2024
Date Signed: 07/16/2024 04:30:22 PM

Document Has Been Signed on 07/16/2024 04:30 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/
DIRECTOR:
AIDA URENAFACILITY TYPE:
735
ADDRESS:1720 MERRILL DRIVETELEPHONE:
(408) 475-3015
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY: 6CENSUS: 5DATE:
07/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:55 PM
MET WITH:Naward SmithTIME VISIT/
INSPECTION COMPLETED:
04:28 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) Naward Smith.

One resident and three staff were observed in the facility. 3 resident files and 3 staff files were reviewed. LPA checked residents P&I money with ADM. ADM stated the resident's P&I money was deposited at bank. The facility has residents' ATM cards to access the P&I money. ADM stated the facility keeps the transaction receipts and bank monthly statements. ADM stated only the corporate staff can access residents' bank account current balance. LPA and ADM called the corporate staff to check the account balance with the resident's transaction log balance. 3 residents' bank account balances match with their transaction log balances. Two staff files were observed without health screening forms. The corporate staff sent the two staff health screening forms to the facility via email.

LPA toured the facility inside out with ADM. License, Administrator Certificate, and personal rights posters were observed in the facility. Activity room, family room, Gym room, kitchen, dinning room, office, and three restrooms were inspected. 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. Medication closet, knives closet, and cleaning product closet were observed locked. Room temperature was at 78 degree F, and hot water temperature was at 108 degree F in facility. Flash lights, first aid box, and night lights were observed in the facility.

Fire extinguisher was serviced on 09/13/2023. 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. There are two storage rooms at the back yard. The last time the facility conducted the emergency drill is 7/5/2024.
No citation was noted today. Exit interview was conducted with ADM. This report was provided to ADM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/16/2024
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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