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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600998
Report Date: 06/25/2021
Date Signed: 06/25/2021 02:38:27 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:PARADISE GARDENS CARE HOMEFACILITY NUMBER:
075600998
ADMINISTRATOR:LISING, ARSENIA E.FACILITY TYPE:
740
ADDRESS:686 MINERT ROADTELEPHONE:
(925) 944-9147
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:6CENSUS: 6DATE:
06/25/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Ritchie Castro, House ManagerTIME COMPLETED:
02:45 PM
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On 06/25/21 at 1:30PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an infection control annual inspection and explained the purpose of the visit with house manager. LPA spoke with administrator on the phone who authorized the house manager to sign the reports. Facility has a completed mitigation plan in place dated 03/04/21 to mitigate the spread of COVID-19. LPA discussed the completed mitigation plan (LIC 808) with house manager as well as COVID-19 infection control practices. LPA inspected the facility inside and outside. LPA observed a screening station located near the front entrance with visitor's log, hand sanitizer, gloves, face masks, no touch temperature probe. Routine symptom screening (+/-) temperature and symptom check) is done at entry for all staff, residents and visitors.

LPA observed COVID-19 signages posted in common areas to promote hand washing, cough/sneeze etiquette and physical distancing. Facility documents daily temperatures and COVID-19 symptom checks for staff and residents. Pathways were observed to be free of obstruction and fire hazards. A written emergency/disaster plan was observed last updated on 05/21/21.

Continued on next page LIC 809-C
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021
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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: PARADISE GARDENS CARE HOME
FACILITY NUMBER: 075600998
VISIT DATE: 06/25/2021
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Infection control designated leader is the administrator. All staff and residents have been fully vaccinated since March 2021.There was at least 7 days of nonperishable and 2 days of perishable foods. Emergency food supplies were observed stored in the garage. Facility room temperature was maintained at 73 degrees Fahrenheit. Medications were observed locked in the dining cabinet. Toxic chemicals were observed locked in the bathroom closet. A certified administrator is on site a minimum of 20 hours a week to oversee proper business operation and compliance with COVID-19 infection control practices. Fire extinguisher was observed fully charged and last inspected on 06/20/21. Smoke and Carbon monoxide detectors were operational.

Updated copies of the following documents were requested to be emailed to LPA on 06/28/21:
· LIC500- Personnel Report
· LIC308- Designation of Facility Responsibility
· LIC610E- Emergency/Disaster Plan
· Evidence of Liability Insurance

No deficiencies were observed during the infection control annual inspection.
Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021
LIC809 (FAS) - (06/04)
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