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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
075600998
Report Date:
05/05/2023
Date Signed:
05/05/2023 07:55:55 PM
Document Has Been Signed on
05/05/2023 07:55 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:
5
DATE:
05/05/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
01:30 PM
MET WITH:
Staff Member Marie Regacho
TIME COMPLETED:
08:15 PM
NARRATIVE
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On 05/05/2023 at 1:30 PM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to conduct a Required Annual Inspection. Upon entry, LPA stated the purpose of the visit with Staff Member Anabel Adviento.
Staff Member Marie Regacho toured the facility inside and outside with the LPA and during the inspection, the LPA spoke with Licensee Arsenia Lising by phone on 2 occasions. The LPA interviewed 2 residents and 1 staff member, and reviewed a portion of the facility, personnel, and resident records.
During this inspection, 3 A-Type and 6 B-Type citations were issued (refer to LIC809-D for details). One Civil Penalty was issued (refer to LIC421FC for details). 3 Technical Violations issued for violations of the regulations that do not pose a risk to the health and safety of persons in care.
Additional visit required to complete the Required Annual Inspection for this facility.
Updated copies of the following documents have been requested. They are to be submitted to CCL on or before 05/12/2023:
· LIC500 - Personnel Report
· LIC610D - Emergency/Disaster Plan
· Evidence of Current Liability Insurance
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:
05/05/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/05/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
1
of
6
Document Has Been Signed on
05/05/2023 07:55 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:
05/05/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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4
Based on observation, the licensee did not comply with the section cited above by using pre-filled containers to store medications for all residents, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
05/06/2023
Plan of Correction
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3
4
On or before due date, Licensee shall inform LPA that all medications have been removed from non-original containers and that only a small transfer cup shall be used to dispense medications to residents in the future.
Type A
Section Cited
CCR
87705(e)
Care of Persons with Dementia
(e) Swimming pools and other bodies of water shall be fenced and in compliance with state and local building codes.
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 by leaving the gate into the pond unlocked, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
05/06/2023
Plan of Correction
1
2
3
4
Licensee locked gate during visit, clearing deficiency.
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:
05/05/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/05/2023
LIC809
(FAS) - (06/04)
Page:
2
of
6
Document Has Been Signed on
05/05/2023 07:55 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:
05/05/2023
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 by leaving the knife drawer unlocked, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
05/06/2023
Plan of Correction
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2
3
4
Licensee locked knife drawer during visit, clearing the deficiency.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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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:
05/05/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/05/2023
LIC809
(FAS) - (06/04)
Page:
3
of
6
Document Has Been Signed on
05/05/2023 07:55 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:
05/05/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(2)
Personal Accommodations and Services
(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.
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 at 1 of the 2 gates stuck closed, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
05/12/2023
Plan of Correction
1
2
3
4
On or before due date, Licensee shall inform LPA that the gate stuck closed has been repaired so it will open freely.
Type B
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in the backyard where poisons , paint, plant food, and other dangerous items have been left out in backyard and accessible to residents, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
05/12/2023
Plan of Correction
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2
3
4
On or before due date, Licensee shall inform LPA that all of the above items dangerous to residents have been removed from the backyard accessible to residents.
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:
05/05/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/05/2023
LIC809
(FAS) - (06/04)
Page:
4
of
6
Document Has Been Signed on
05/05/2023 07:55 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:
05/05/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)(1)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.
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 where storage areas for poisons in the backyard were left unlocked, propped open, or missing any door at all, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
05/12/2023
Plan of Correction
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2
3
4
On or before due date, Licensee shall inform LPA that all poisons have been stored in locked cabinets or removed completely from the backyard.
Type B
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
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 where toxic substances were left out and accessible to residents with dementia, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
05/12/2023
Plan of Correction
1
2
3
4
On or before due date, Licensee shall inform LPA that all toxic sbstances have been stored in locked cabinets or removed completely from the backyard.
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:
05/05/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/05/2023
LIC809
(FAS) - (06/04)
Page:
5
of
6
Document Has Been Signed on
05/05/2023 07:55 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:
05/05/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(h)
Care of Persons with Dementia
(h) Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents.
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 at 2 of the 2 gates that are not self-closing, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
05/12/2023
Plan of Correction
1
2
3
4
On or before due date, Licensee shall inform LPA that 2 of the 2 gates have had a self-closing mechanism installed and are therefore self-closing.
Type B
Section Cited
CCR
87705(j)
Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.
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 on the exit and entrance doors of the facility, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
05/12/2023
Plan of Correction
1
2
3
4
On or before due date, Licensee shall inform LPA that working auditory devices have been installed on all entrance and exit doors of the facility.
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:
05/05/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/05/2023
LIC809
(FAS) - (06/04)
Page:
6
of
6