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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294024
Report Date: 07/19/2023
Date Signed: 07/29/2023 08:34:49 PM

Document Has Been Signed on 07/29/2023 08:34 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:PACIFIC GARDENSFACILITY NUMBER:
435294024
ADMINISTRATOR:ZAHODNE, MATTHEWFACILITY TYPE:
740
ADDRESS:2384 PACIFIC DRTELEPHONE:
(408) 985-5252
CITY:SANTA CLARASTATE: CAZIP CODE:
95051
CAPACITY: 104CENSUS: 59DATE:
07/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Administrator MATTHEW ZAHODNETIME COMPLETED:
06:00 PM
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Licensing Program Analyst (LPA) Manuel Monter, Simi Rai and LPM Manzano conducted an unannounced annual inspection. LPA met with Executive Director (ED) Matt Zahodne.

LPA's toured the facility inside and out. LPA's inspected 5 assisted living residence and 1 memory care residence. The memory care/ assisted living unit residents rooms were found clear of debris, with beds, clean linens, bath rails and shower mats, locked cabinets in each room for staff to secure cleaning toxins. LPA's also toured the kitchen, activity room for both the assisted living and memory care. The facility has a centralized fire alarm system connected to Santa Clara County fire. ADM stated the alarm system is tested annually (last inspection 8/23/2022). Each resident room has an individual fire detector. Fire extinguishers serviced 6/22/2023. The facility conducts earthquake and fire drills monthly 4/30/2023 and staff are trained for emergency shut off values and generators. Note: the memory care second floor is un-operational and off limits to residents. & ADM will need to inform LPA if the area is opened.

While touring the outside of the facility, LPA's observed gardening tools and a lawn mower close to the facility's garden area. ADM stated that residents participate in gardening activities. These gardening tools were accessible to residents in care. ADM stated they will move gardening tools and lawn mower to secured locked area.

While touring the facility kitchen, LPA's observed sufficient food supply for 2 day perishable and 7 day non-perishable for census of 59, supplied by Sysco food services.

LPA's measured the water temperature in the following areas; activity room, 3 assisted living units, 1 memory care unit, 1 memory care bathroom, Assisted living activity room sink. The water temperature was measured and ranged from 107-109 degree F.
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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 07/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/19/2023
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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: PACIFIC GARDENS
FACILITY NUMBER: 435294024
VISIT DATE: 07/19/2023
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While touring resident R2's room, LPA's observe over the counter medication at the resident's table. ADM and LPAs review resident file and R2 did not have physician's order for over the counter medication. ADM clarified with R2 and R2's family brought the over the counter medication without the ADM knowledge. LPA Rai advised ADM to inform residents and resident's responsible parties to inform the facility directors for any over the counter medications and prescription medication.

Facility needs to also observe for changing of resident's conditions in terms of medication management. The facility staff need to observe the resident and ensure residents are taking their medication when residents are not on facility's medication management.

LPA reviewed a random selection (5%)of clients and staff files. 3 out of 3 clients' records were reviewed and were complete such as Needs and Services Care plans and physicians assessments/TB clearances. 3 Out of 3 Staff files were reviewed with current training, required training, including first aid and CPR on file, physicians assessments/TB clearances, and are fingerprint cleared and associated. 3 residents and 3 staff were interviewed.

Exit interview was conducted with Matt Zahodne. A technical violation was provided. This report was provided to ADM for signature.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2023
LIC809 (FAS) - (06/04)
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