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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294024
Report Date: 01/18/2024
Date Signed: 01/18/2024 03:55:36 PM


Document Has Been Signed on 01/18/2024 03:55 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: 62DATE:
01/18/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Administrator, Matthew ZahodneTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced case management visit regarding an Incident Report sent the Department. LPA met with Administrator (ADM) Matthew Zahodne and stated the purpose of the visit.

On 1/11/2024, the Department received an Incident Report for resident (R1) for an incident which occurred on 1/6/2024 where R1 climbed out of his/her bedroom window and was found walking outside of the back of the building.

During today's visit, LPA Rai conducted 4 interviews with staff, (S1-S3) including ADM. LPA reviewed R1's records to include R1's Appraisal 11/2/2023, Functional Capability 11/2/2023, Appraisal/Needs and Services Plan dated 12/18/2023 & 1/6/2023 and Physician's Report dated 11/1/2023 & 12/13/2023. LPA Rai reviewed R1 is not able to leave the facility unattended and R1 is diagnosed with Dementia.

LPA Rai observed R1's current room and observed window stoppers placed in the window. ADM stated the maintenance team will be placing window stoppers on all windows in the Memory Care Department.

No deficiencies were cited at this time as per California Code of Regulations Title 22. Technical Assistance and Technical Violation was provided.

This report was reviewed with Administrator Matthew Zahodne and a copy of the report was provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2024
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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