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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294024
Report Date: 07/22/2021
Date Signed: 07/23/2021 08:08:11 AM

Document Has Been Signed on 07/23/2021 08:08 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:PACIFIC GARDENSFACILITY NUMBER:
435294024
ADMINISTRATOR:ZAHODNE, MATTHEWFACILITY TYPE:
740
ADDRESS:2384 PACIFIC DRTELEPHONE:
(408) 985-5252
CITY:SANTA CLARASTATE: CAZIP CODE:
95051
CAPACITY: 104CENSUS: 48DATE:
07/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Matt ZahodneTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Joanne Roadilla conducted an unannounced Infection Control site visit today. LPA met with Executive Director (ED) Matt Zahodne and Director of Resident Care Services (DRCS) Mia Cabana.

LPA toured the facility inside and out with DRCS. Facility was observed to have a designated entry point for universal symptom screening including temperature check and a questionnaire log. Hand sanitizers were available throughout the facility. All staff present were observed wearing masks.

Restrooms were observed supplied with hygiene products and with hand washing signs. Bedrooms and bathrooms were inspected randomly. The kitchen, dining room, common/activity rooms, and the exterior of the facility were also inspected. All fire exit routes were observed clear of obstruction. Medications are secured and only accessible to staff.

LPA reviewed the facility COVID-19 related infection control policies and procedures with ED and DRCS including surveillance testing, disinfecting, staffing, training, isolation, PPE use and inventory. Facility has a COVID-19 mitigation plan in place.

No deficiencies issued per Title 22 of the California Code of Regulations. LPA reviewed report with and a copy provided to Matt Zahodne.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Joanne Roadilla
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2021
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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