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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200965
Report Date: 09/07/2021
Date Signed: 09/30/2021 11:14:37 AM

Document Has Been Signed on 09/30/2021 11:14 AM - 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 - LAMAR HOUSEFACILITY NUMBER:
435200965
ADMINISTRATOR:SABRA NAKAMOTOFACILITY TYPE:
735
ADDRESS:854 GARY AVENUETELEPHONE:
(408) 715-4340
CITY:SUNNYVALESTATE: CAZIP CODE:
94086
CAPACITY: 6CENSUS: 6DATE:
09/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Helena SerpaTIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Yatfai Eric Ng conducted an unannounced infection control site visit. LPA met with the Direct Support Professional (DSP) Desta Alemayehu. Later came the Direct Care Staff (DCS) Helena Serpa.

One central entry point was designated for all staff, residents, and visitors. A temperature screening station and sign in sheet were present at the entrance. LPA was screened by DSP before entering.

LPA toured the facility. The facility was observed to be in sanitary condition. All staff members were observed to be wearing masks. There were COVID-19 signs at the entrance and throughout the facility.

LPA inspected 2 restrooms. The restrooms were observed to be adequately stocked with paper towels and hand soap. Hand washing signs were present.

LPA discussed the infection control with DCS. LPA made recommendations and discussed the current Provider Information Notice PIN 21-40-ASC. 6 out of 6 residents were fully vaccinated per DCS. All staff present were fully vaccinated also.

Advisory note (LIC 9102) was issued. No deficiency cited during visit.

This report was reviewed with DCS.

A copy of this report and advisory note were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Yatfai Ng
LICENSING EVALUATOR SIGNATURE: DATE: 09/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/07/2021
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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