075600998-5-27-2022-15-AS-JSAR-CETRNP-20220527131039

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075600998
Report Date: 05/27/2022
Date Signed: 05/27/2022 01:12:50 PM

Document Has Been Signed on 05/27/2022 01:12 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	PARADISE GARDENS CARE HOME		FACILITY NUMBER:	075600998
ADMINISTRATOR:	LISING, ARSENIA E.		FACILITY TYPE:	740
ADDRESS:	686 MINERT ROAD		TELEPHONE:	(925) 944-9147
CITY:	WALNUT CREEK	STATE: CA	ZIP CODE:	94598
CAPACITY:	6	CENSUS:	DATE:	05/27/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Ritchie Castro		TIME COMPLETED:	01:15 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	On 05/27/22 at 9:00AM, Licensing Program Analyst (LPA) James Sampair conducted an infection control annual inspection. LPA explained the purpose of the visit with staff member Ritchie Castroupon entry and toured facility with LPA inside and out. Facility has a COVID-19 mitigation plan in place dated 03/01/21 that they are following. The designated infection control leader is the administrator. They have one central entry point that has been designated for universal entry screening with the station located near the front entrance with visitor's log, hand sanitizer, face masks, and no touch temperature probe. Facility follows daily cleaning, sanitation of frequently touched common surfaces with disinfectants. COVID-19 signs were not posted throughout the facility to promote hand washing, cough/sneeze etiquette and physical distancing for which they were cited. All staff and clients have been fully vaccinated. The LPA and the staff member discussed the infection control plan from the PIN 22-13-ASC that will need to be created for the 06/30/22 due date.. A written Emergency/Disaster plan was posted on the bulletin board for staff, clients and visitors to read. Centrally stored medications were in locked cabinets. The temperature inside of the facility was 73.0 degrees and in the safe range. The hot water, however, was 140 degrees, which is far outside of the safe range of 105 to 120 degree Fahrenheit. Toxic chemicals were stored in locked closets and cabinets. However, sharp objects were not, again a Type A deficiency for which they were cited. Continued on next page LIC 809-C

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James Sampair	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022

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: 05/27/2022

NARRATIVE

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Administrator is on site a minimum of 20 hours a week to oversee proper business operation. LPA observed fire extinguisher was fully charged and purchased in June of 2021. Cited for the Smoke and Carbon monoxide detectors that were not operational.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 06/03/22:

· LIC500 - Personnel Report
· LIC308 - Designation of Facility Responsibility
· LIC610E - Emergency/Disaster Plan
· Evidence of Liability Insurance & Surety Bond

Facility cited for 2 Type A and 3 Type B deficiencies during this visit.

Exit interview conducted and a copy of this report provided via email.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James Sampair	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/27/2022 01:12 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(1)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in the kitchen where the knives are stored were in an unlocked drawer which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/29/2022
	Plan of Correction
1 2 3 4	Licensee shall move knives to a location inaccessible to residents and send proof to LPA by POC due date.

Type A

Section Cited

CCR

87303(e)(2)

Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above because the hot water temperature was measured at 140 degrees Farenheit, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/28/2022
	Plan of Correction
1 2 3 4	The Licensee shall reduce the maximum hot water temperature to the safe level of 105 to 120 degree Farenheit by the POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James Sampair	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/27/2022 01:12 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87468.1(a)(2)

Personal Rights of Residents in all Facilities

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in with their Infection Control Practices, because no signs were posted at facility entrance or inside of the facility with updates or reminders about Covid-19 protections, in accordance with personal rights requirements. This practice has a health and safety impact that includes, but is not limited to buildings and grounds, personnel requirements and personal rights.
	POC Due Date: 06/03/2022
	Plan of Correction
1 2 3 4	Licensee shall post Covid-19 signage at entrance to facility as well as locations within facility as reminders of masking, physical distancing, and coughing behavior and send proof to LPA by POC due date.

Type B

Section Cited

HSC

1569.695(c)

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and staff interview, the licensee does not have proof that they are complying with the section cited above, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/03/2022
	Plan of Correction
1 2 3 4	Administrator has agreed to send proof of the quarterly fire/disaster drills to CCL by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James Sampair	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 05/27/2022 01:12 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87203

87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above because niether the Smoke and Carbon Monoxide alarms and detectors were operational which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/03/2022
	Plan of Correction
1 2 3 4	Licensee shall install working Smoke and Carbon Monoxide alarms and detectors and inform the LPA by the POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James Sampair	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022

LIC809 (FAS) - (06/04)

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