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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294024
Report Date: 01/27/2025
Date Signed: 01/27/2025 03:48:10 PM

Document Has Been Signed on 01/27/2025 03:48 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: 69DATE:
01/27/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Administrator, Matt ZahodneTIME VISIT/
INSPECTION COMPLETED:
03:55 PM
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Licensing Program Analyst (LPA) Simi Rai arrived unannounced to conduct an case management visit to follow up on Incident Report/Death Report for resident (R1) who sustained injury from a witnessed fall and passed away a few days later. LPA Rai met with Administrator (ADM) Matt Zahodne and stated the purpose of today's visit.

On 1/21/2025, the Department received an Incident Report for an incident which occurred on 1/13/2025 wherein R1 had a witnessed fall in the activity area in the Memory Care unit while participating in ball toss activity. R1 stood up and lost balance and fell to the floor. The facility staff called the paramedics and R1 was taken to the hospital.

The Department received a Death Report on 1/24/2025 wherein R1 passed away at family member's home under Hospice services after being discharged from the hospital on 1/17/2025.

During today's visit, LPA Rai interviewed one staff (S1) and ADM.

LPA Rai obtained copy of R1's Physician's Report dated 11/4/2024 and staff training records such as "Identifying Fall Risk in Assisted Living" for staff working during the shift of 1/13/2025.

ADM stated to provide a copy of the Death Certificate when it becomes available.

At this time, LPA Rai determined this case management needs further investigation.

The report was reviewed with Administrator (ADM) Matt Zahodne and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2025
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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