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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601215
Report Date: 12/16/2021
Date Signed: 12/16/2021 07:12:15 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 HOME IIFACILITY NUMBER:
075601215
ADMINISTRATOR:LISING, ARSENIA E.FACILITY TYPE:
740
ADDRESS:197 LOS CERROS AVENUETELEPHONE:
(925) 944-9147
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:6CENSUS: 5DATE:
12/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Staff Members Marie Fe Regacho and Rico PaguioTIME COMPLETED:
07:30 PM
NARRATIVE
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On 12/16/2021 at 1:00PM, Licensing Program Analyst (LPA) James Sampair arrived unannounced and met with Staff Members Marie Fe Regacho and Rico Paguio. The LPA explained the reason for the visit, which was to conducted an infection control annual inspection.

Accompanied by the staff members, the LPA toured the facility inside and out. The facility has a completed COVID-19 mitigation plan (LIC 808). The LPA observed that staff were only following some of the Department and Public Health Covid-19 infection control guidelines. They were screening of all visitors and staff upon entry, Covid-19 signs were posted at the single entry point into and throughout the facility to promote hand washing, cough and sneeze etiquette, physical distancing, and mask wearing. However, upon LPA Sampair's arrival, Mr. Paguilo was not wearing a mask. They were using cloth and not paper towels in the bathrooms. They did not have adequate PPE supplies. The staff had not been adequately trained in Covid-19 infection control

The facility was clean, well maintained, and no obstructions. However, there was a great deal of junk on the side of the facility and a piano in the driveway, all of which needed to be removed or relocated. There were sufficient supplies of food and paper supplies. The temperature within the facility was maintained at a comfortable level. A certified administrator is on site more than the minimum of 20 hours a week to oversee proper business operation.

The facility was cited for five different deficiencies as listed in the LIC809-Ds.

An exit interview conducted and a copy of this report and Appeal Rights were provided to the ADM.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2021
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 5
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 II
FACILITY NUMBER: 075601215
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(d)(5)
Personnel Requirements - General
(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: (5) Knowledge necessary in order to recognize early signs of illness and the need for professional help.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation and record review, the licensee did not comply with the section cited above by not adequately training staff on infection prevention, symptoms, transmission, and PPE use, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/23/2021
Plan of Correction
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1. Complete the Covid-19 Facility Self-Assessment Guide (https://cdss.ca.gov/Portals/9/CCLD/COVID/COVID-19_FacilitySelfAssessment_Guide.pdf) AND
2. Thoroughly study and complete the exercises in the Covid-19 Playbook (https://cdss.ca.gov/Portals/9/CCLD/COVID/COVID19-Playbook.pdf) on or before the POC due date.
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in the outside of the facility because of the empty pond that must be covered, the dead tree in backyard that must be removed, and the junk on side of building, and piano out front must be cleared, which pose a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/30/2021
Plan of Correction
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Send proof to LPA Sampair that those removals or relocations have been completed with digital pictures
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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2021
LIC809 (FAS) - (06/04)
Page: 2 of 5
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 II
FACILITY NUMBER: 075601215
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above with the requirement to train staff adequately, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/23/2021
Plan of Correction
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Must show proof of adequate staff training in the past or new training must be scheduled to make up for what has been missed over the past 2 years since the latest proof of training observed was from 2019.
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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2021
LIC809 (FAS) - (06/04)
Page: 3 of 5
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 II
FACILITY NUMBER: 075601215
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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4
Based on record review, the licensee did not comply with the section cited above with the training for the staff members, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/23/2021
Plan of Correction
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Proof to LPA that all staff have been registered in appropriate training that includes in-person training.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2021
LIC809 (FAS) - (06/04)
Page: 4 of 5
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 II
FACILITY NUMBER: 075601215
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in providing a 30-day supply of PPE on hand (e.g., facemasks, respirators, gowns and gloves), which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/30/2021
Plan of Correction
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Provide photographic proof that adequate supplies have been obtained and delivered to the facility to LPA Sampair (since you have 2 facilities it is adequate to share a 30-day supply between the 2 facilities).
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2021
LIC809 (FAS) - (06/04)
Page: 5 of 5