435294024-7-2-2021-26-AS-JROA-C4K489-20210702185220

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435294024
Report Date: 07/02/2021
Date Signed: 07/02/2021 06:52:39 PM

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:	PACIFIC GARDENS		FACILITY NUMBER:	435294024
ADMINISTRATOR:	ZAHODNE, MATTHEW		FACILITY TYPE:	740
ADDRESS:	2384 PACIFIC DR		TELEPHONE:	(408) 985-5252
CITY:	SANTA CLARA	STATE: CA	ZIP CODE:	95051
CAPACITY:	104	CENSUS: 50	DATE:	07/02/2021
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	03:55 PM
MET WITH:	Matt Zahodne		TIME COMPLETED:	06:05 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Joanne Roadilla conducted an unannounced Case Management visit today. LPA met with Executive Director Matt Zahodne and Director of Resident Care Services (DRCS) Mia Cabana. The purpose of the visit was to follow up on a report received by the Department on 07/01/21 that on 06/30/21, a resident (R1) fell off the back of the company van. At around 4pm, LPA interviewed ED and DRCS. Per ED, resident was coming back from a medical appointment and driver had just removed the safety harnesses attached to the bottom of wheelchair and the seat belt around the wheelchair. Driver was coming around from the inside of the van to move to the back of the van to assist the resident out when the driver saw from driver's peripheral vision that resident was starting to fall backwards in the wheelchair. Driver ran back and tried to grab the resident and fell out of the back of the van with the resident. ED stated there were no witnesses to the fall except for the driver. ED stated another staff from inside the facility saw from the window that resident's family member was nearby waiting for the resident to come out of the van then ran to the van after the incident. Per ED, it is company policy that driver assists the resident to and from the van, no other staff assists unless the clients have dementia or needs further assistance. Driver was trained by Director of Environmental Services and has been working as a driver at the facility for at least 14 years. Per ED's statements, there was no evidence of lack of supervision from the driver. Continued on 809-C.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Joanne Roadilla	TELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: PACIFIC GARDENS	FACILITY NUMBER: 435294024
	VISIT DATE: 07/02/2021

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At around 4:30pm, LPA inspected the van with ED and DRCS. ED stated the van was parked at roughly the same place as where it was parked during the incident. ED showed a picture of the van right after the incident. LPA observed the inside of the van with a safety harness, seat belt and ramp that were fully functional. A wheelchair was placed inside the van and LPA sat on it and observed the chair does not move around even when the brakes are not engaged. LPA also observed the edge of the van had a wedge/small ramp that serves as a safety feature so the wheelchair does not go over without intervention. This safety feature also has an alarm that was observed would beep when touched.

LPA reviewed and obtained a copy of R1's physician report, Appraisal/Needs and Services Plan and Functional Capability Assessment.

No deficiencies cited during today's visit. Report was discussed with and a copy provided to Matt Zahodne.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Joanne Roadilla	TELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021

LIC809 (FAS) - (06/04)

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