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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294024
Report Date: 08/14/2024
Date Signed: 08/14/2024 05:13:34 PM

Document Has Been Signed on 08/14/2024 05:13 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/
DIRECTOR:		ZAHODNE, MATTHEWFACILITY TYPE:
740
ADDRESS:2384 PACIFIC DRTELEPHONE:
(408) 985-5252
CITY:SANTA CLARASTATE: CAZIP CODE:
95051
CAPACITY: 104CENSUS: 66DATE:
08/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Director of Resident Care Services, Mia EvangalistaTIME VISIT/
INSPECTION COMPLETED:
05:20 PM
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Licensing Program Analysts (LPAs) Simi Rai and Marcella Tarin conducted an unannounced Required 1 Year visit. LPAs met with Director of Resident Care Services, Mia Evangalista and stated the purpose of today's visit. LPAs spoke with Administrator Matthew Zahodne over the phone and stated the purpose of today's visit. Administrator gave permission for Director of Resident Care Services, Mia Evangalista to review and sign this report.

During visit, LPAs toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPAs Rai and Tarin toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Sharps and medications were locked in secured areas. LPAs observed additional food supply areas and secured areas for cleaning supplies and laundry detergents.

LPAs toured at random 7 resident bedrooms. 7 out of 7 resident bedrooms had available bedding, drawers, and functioning lights. The facility bathroom had available soap, paper towels, and trash cans with lids. The water temperature in the bathroom sinks ranged from between 105 degrees F and 120 degrees F.
Fire extinguisher was observed and inspected on 04/09/2024. Facility smoke detectors and carbon monoxide detectors were in working condition. Third party vendor was on premise during today's visit and tested all smoke detectors and carbon monoxide detectors. The last disaster drills were conducted on 4/21/2024 and 7/28/2024.

LPAs reviewed facility records for 7 staff and 7 residents. LPA Rai reviewed resident medications and central stored medication records.

No deficiencies were cited per California Code of Regulations, Title 22. Technical Violations were provided during visit. LPAs discussed the report with Administrator Matthew Zahodne over the phone. This report was reviewed with Director of Resident Care Services, Mia Evangalista and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2024
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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