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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200321
Report Date: 07/16/2024
Date Signed: 07/16/2024 04:29:37 PM

Document Has Been Signed on 07/16/2024 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:PACE - MATRANGA HOUSEFACILITY NUMBER:
435200321
ADMINISTRATOR/
DIRECTOR:
NAWARD SMITHFACILITY TYPE:
735
ADDRESS:2318 NEW JERSEY AVENUETELEPHONE:
(408) 475-0253
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY: 6CENSUS: 6DATE:
07/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:NAWARD SMITHTIME VISIT/
INSPECTION COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) Naward Smith.

3 staff and 1 residents were observed in the facility. LPA reviewed 3 residents files and 3 staff files. LPA checked residents P&I money with ADM. ADM stated the facility has residents ATM cards to access P&I money. ADM stated the facility keeps the ATM cards, the transaction receipts and bank monthly statements, and only the corporate staff can access residents' bank account current balance. ADM called the corporate staff to make sure the transaction log balance and bank account current balance matches.

LPA toured the facility inside out with ADM. License, Administrator Certificate, and personal rights posters were observed in the facility. Living room, kitchen, dinning room and three restrooms were inspected. Four single resident bedrooms, one shared resident room, one office, garage 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 71 degree F, and hot water temperature was at 118 degree F in facility. The temperature of the refrigerator was at 37 degree F, and the temperature of the freezer is at 0 degree F. 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 staff, and were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways. One storage room was observed in the backyard. The last time the facility conducted emergency drill is 7/12/2024.
No citation were 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: 07/16/2024
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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