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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200321
Report Date: 03/18/2022
Date Signed: 03/18/2022 03:29:43 PM

Document Has Been Signed on 03/18/2022 03:29 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:PACE - MATRANGA HOUSEFACILITY NUMBER:
435200321
ADMINISTRATOR:NAWARD SMITHFACILITY TYPE:
735
ADDRESS:2318 NEW JERSEY AVENUETELEPHONE:
(408) 475-0253
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY: 6CENSUS: 6DATE:
03/18/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Naward SmithTIME COMPLETED:
09:46 AM
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Licensing Program Analyst (LPA) Steve Chang, and Licensing Program Manager (LPM) Romeo Manzano, and Program Clinical Consultant (PCC) Helen Shi conducted Technical Assistant through tele-inspection (Zoom), and met with Administrator (ADM) Naward Smith.

The purpose of this TA Tele visit was to review the facility COVID-19 infection mitigation plan and conducted inspection of the facility to ensure plan is being carried out and to provide support and guidance to staff in mitigating the spread of virus.

During tele-visit inspection, a tour of the facility was conducted which started at the main entrance to check COVID-19 signage and screening procedures. The facility has COVID-19 posters at the main entrance door. As you enter to the facility, they had hand sanitizer, face masks, thermometer, glove.

The facility common areas were inspected such as the kitchen, living room, dinning area, and bathrooms. Trash cans were observed with covers. A wash cloth towels were observed in the kitchen. The laundry room was observed and inspected. The resident bedrooms were inspected. Residents' bed in one of the shared room was observed in 6 feet apart.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 - MATRANGA HOUSE
FACILITY NUMBER: 435200321
VISIT DATE: 03/18/2022
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Based on today's inspection, the facility is being recommended the following:

1. Facility to develop and submit a copy of COVID questionnaires for visitors at the screening station. Health screening questionnaires should have the symptoms of COVID-19, exposures and travel information and etc.
2. Facility to post COVID-19 signage at common area including kitchen and bathrooms such as masking, donning and doffing PPE, social distancing, and hand washing for 20 seconds.
3. Facility to conduct staff training at least monthly or frequently such as donning and doffing PPE and COVID -19 updates by CDC, local public health and to review DSS-CCLD (Providers Information Notice-PINS). CCLD website: www.ccld.ca.gov.
4. Facility use of N95 mask by staff must have completed a N95 mask fitting test conducted by medical professional per CalOSHA. ADM stated facility Human Resources will be contacted regarding CalOSHA requirements.
5. Facility to ensure that dirty laundry for negative and positive residents are separated by washing negative residents first, then do the laundry for the positive residents.
6. Facility to ensure staff use high water temperature when washing laundry for COVID positive case.
7. Facility to ensure to designate a isolation room for future COVID-19 cases.
8. Facility to review their Infection Mitigation plan and submit addendum if needed.
9. Facility to mount the paper towel or put in the dispenser in the shared bedroom's restroom.

LPA also provided COVID-19 information links/website to ADM via email.


No deficiencies cited during today's Tele Visit. Exit interview conducted with ADM.
A copy of this report emailed to ADM for signature.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022
LIC809 (FAS) - (06/04)
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