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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200965
Report Date: 10/27/2022
Date Signed: 10/27/2022 02:11:05 PM

Document Has Been Signed on 10/27/2022 02:11 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:PACE - LAMAR HOUSEFACILITY NUMBER:
435200965
ADMINISTRATOR:AIDA URENAFACILITY TYPE:
735
ADDRESS:854 GARY AVENUETELEPHONE:
(408) 715-4340
CITY:SUNNYVALESTATE: CAZIP CODE:
94086
CAPACITY: 6CENSUS: 6DATE:
10/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Rey BustamanteTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Rey Bustamante.

During visit, LPA Marrufo toured the inside and outside of the facility. LPA Marrufo observed a visitor screening area at the facility entrance. LPA Marrufo observed a perishable food supply of at least 2 days and a non-perishable food supply of at least 7 days. LPA Marrufo observed a PPE supply of at least 30 days. 2 out of 2 hallway bathrooms had available soap, paper towels, and hand washing signs.

No deficiencies were cited at this time as per Califorina Code of Regulations Title 22.

This report was reviewed with Rey Bustamante and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2022
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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