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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
075601215
Report Date:
10/10/2022
Date Signed:
10/10/2022 05:49:26 PM
Document Has Been Signed on
10/10/2022 05:49 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 II
FACILITY NUMBER:
075601215
ADMINISTRATOR:
LISING, ARSENIA E.
FACILITY TYPE:
740
ADDRESS:
197 LOS CERROS AVENUE
TELEPHONE:
(925) 944-9147
CITY:
WALNUT CREEK
STATE:
CA
ZIP CODE:
94598
CAPACITY:
6
CENSUS:
5
DATE:
10/10/2022
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
09:30 AM
MET WITH:
Staff Member Rico Paguio
TIME COMPLETED:
06:15 PM
NARRATIVE
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On 10/10/2022, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to conduct an infection control annual inspection. LPA explained reason for the visit, but the Administrator was sick so LPA met with Staff Member Rico Paguio, who accompanied LPA to tour the facility inside and out.
The administrator is the designated infection control leader. The staff had not been trained on, nor could they find a copy of the Infection Control Plan the Licensee had sent to the Department on 08/05/2022. LPA observed that staff followed only some Covid-19 infection control guidelines. They were not checking or recording temperatures of visitors or staff upon entry. They had few PPE supplies. No masking or Covid-19 signs were posted.
The facility was clean, well maintained, and no obstructions. There was a sufficient supply of perishable and nonperishable food on hand, though the refrigerated and frozen food had no date when opened. The fire extinguisher has been serviced within the past 12 months. The carbon monoxide and smoke detectors were fully functional. The temperature inside of the facility was 71.6 and the hot water was 118 degrees. 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 2 A-Type and 6 B-Type deficiencies (refer to LIC809-D forms), as well as 2 civil penalties for repeat violations.
By 10/17/2022, Licensee will send updated forms to LPA:
· LIC500 - Personnel Report
· LIC308 - Designation of Facility Responsibility
· LIC610E - Emergency/Disaster Plan
· Evidence of Liability Insurance
Exit interview conducted, copy of Appeal Rights, 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:
10/10/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/10/2022
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
Document Has Been Signed on
10/10/2022 05:49 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 II
FACILITY NUMBER:
075601215
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/10/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(28)
General Food Service Requirements
(b) The following food service requirements shall apply: (28) All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery.
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. Previously opened food in resident and staff refrigerators and freezers was not labeled with date it had been opened, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
10/11/2022
Plan of Correction
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2
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4
Label all containers of previously opened food with date opened. Send picture proof to LPA by due date.
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
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4
Based on observation, the licensee did not comply with the section cited above for unlocked 2 sharps drawers with scissors, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
10/11/2022
Plan of Correction
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4
Cleared during visit.
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:
10/10/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/10/2022
LIC809
(FAS) - (06/04)
Page:
2
of
5
Document Has Been Signed on
10/10/2022 05:49 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 II
FACILITY NUMBER:
075601215
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/10/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(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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4
Based on observation, the licensee did not comply with the section cited above by not (1) conducting and recording results of routine symptom screening (+/- temperature and symptom check) at entry for all staff, residents, and visitors (2) having a 30-day supply of PPE (e.g., facemasks, respirators, gowns, gloves, and eye protection such as face shield or goggles), which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/17/2022
Plan of Correction
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Get proof to LPA that a both the COVID-19 screening and the 30-day supply of PPE (okay to share between facilities) has been obtained on or before the due date.
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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Based on observation and interview, the licensee did not comply with the section cited above. Staff have been told the wrong information about protection from COVID-19 and Inadequate training on infection prevention, symptoms, transmission and PPE use by an individual trained in infection control. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/24/2022
Plan of Correction
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Licensee shall review the latest PINs on the Department website and review that information with staff members, attesting to the completion of those tasks on or before the due date to the LPA.
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:
10/10/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/10/2022
LIC809
(FAS) - (06/04)
Page:
3
of
5
Document Has Been Signed on
10/10/2022 05:49 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 II
FACILITY NUMBER:
075601215
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/10/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87305(a)
Alterations to Existing Buildings or New Facilities
Prior to construction or alterations, all facilities shall obtain a building permit.
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 the Garage as a bedroom for staff, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/17/2022
Plan of Correction
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Licensee shall remove all staff clothing, personal artifacts, bed, and staff bedding from the garage by the due date.
Type B
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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Based on observation, the licensee did not comply with the section cited above in 5 of the 5 resident's medications with the use of transfer containers to dispense them to the residents on a daily basis, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/17/2022
Plan of Correction
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Licensee must remove the transfer containers, update the plan of operation, and retrain staff to dispense the medications to residents directly from the originally received containers at time of dispensing.
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:
10/10/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/10/2022
LIC809
(FAS) - (06/04)
Page:
4
of
5
Document Has Been Signed on
10/10/2022 05:49 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 II
FACILITY NUMBER:
075601215
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/10/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(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
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2
3
4
Based on record review, the licensee did not comply with the section cited above since the last emergency drill that was conducted August 11, 2021, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/17/2022
Plan of Correction
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Licensee shall conduct an emergency drill on or before the due date and attest to LPA that the drill has been conducted via email or text.
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation (c) All window screens shall be clean and maintained in good repair.
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 2 screens on sliding doors were torn on the edge and the rear sliding door is too difficult to open, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/24/2022
Plan of Correction
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Licensee will repair those window screens and the sliding door and send proof the repair to the LPA on or before the 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:
10/10/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/10/2022
LIC809
(FAS) - (06/04)
Page:
5
of
5