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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
075601215
Report Date:
12/24/2024
Date Signed:
12/24/2024 06:17:34 PM
Document Has Been Signed on
12/24/2024 06:17 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
OAKLAND ASC
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
PARADISE GARDENS CARE HOME II
FACILITY NUMBER:
075601215
ADMINISTRATOR/
DIRECTOR:
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
TOTAL ENROLLED CHILDREN:
0
CENSUS:
5
DATE:
12/24/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:
Caregiver Marie Regacho
TIME VISIT/
INSPECTION COMPLETED:
06:30 PM
NARRATIVE
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On 12/24/2024 at 10:30 AM, Licensing Program Analyst (LPA) James Sampair arrived unannounced to conduct the Required Annual Inspection of the facility. Upon arrival, LPA stated the purpose of the visit to Caregiver Junnel Barrosa.
The LPA inspected the inside and outside of the facility. All indoor and outdoor passageways were free of obstruction. Outside, there were no bodies of water. Inside, the temperature in the dining room was 71.8 and the hot water was 110.1 degrees Fahrenheit. The LPA observed adequate lighting in all of the rooms for the comfort and safety of the individuals. The LPA observed more than the minimum of 7 days of nonperishable and 2 days of perishable food on hand. Sharps and other dangerous items were stored inaccessibly to residents. Smoke and carbon monoxide detectors were in operating condition. Fire extinguishers observed to be fully charged and last serviced on 12/10/2024.
The LPA reviewed the records of 5 residents and 5 staff members.
1 A-Type and 6 B-Type citations and a $500 civil penalty were issued (refer to LIC 809-D and Lic 421-BG for details).
Exit interview conducted and a copy of this report provided.
Harpreet Humpal
TELEPHONE:
(510) 529-9416
James Sampair
TELEPHONE:
(510) 286-4201
DATE:
12/24/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/24/2024
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
12/24/2024 06:17 PM
- It Cannot Be Edited
Created By:
James Sampair
On
12/24/2024
at
05:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
,
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:
12/24/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section above. 1 staff member was not associated with the facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
12/26/2024
Plan of Correction
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2
3
4
On or before the due date and before Nenita Williams is allowed in the facility again, she shall be associated with the facility.
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) 529-9416
LICENSING EVALUATOR NAME:
James Sampair
TELEPHONE:
(510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
12/24/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/24/2024
LIC809
(FAS) - (06/04)
Page:
2
of
6
Document Has Been Signed on
12/24/2024 06:17 PM
- It Cannot Be Edited
Created By:
James Sampair
On
12/24/2024
at
05:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
,
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:
12/24/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interviews and record reviews, the licensee did not comply with the section cited above (1) staff records without health screening report and (2) current administrator not in good health and replacement administrator is not associated with facility or completed all requirements for being the administrator in accordance with December 2023 email from LPA Sampair, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
12/31/2024
Plan of Correction
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2
3
4
On or before due date, licensee shall send the missing staff health reports and required documentation to LPA Sampair to appoint Nenita Williams administrator.
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) 529-9416
LICENSING EVALUATOR NAME:
James Sampair
TELEPHONE:
(510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
12/24/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/24/2024
LIC809
(FAS) - (06/04)
Page:
3
of
6
Document Has Been Signed on
12/24/2024 06:17 PM
- It Cannot Be Edited
Created By:
James Sampair
On
12/24/2024
at
05:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
,
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:
12/24/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in (1) front gates: repair latches and self-closing mechanisms; (2) exterior screen door: repair so it closes completely; (3) repair and secure trestles holding vines above walkway and white trestle with disconnected end section; (4) clean out freezer with ice on food; and (5) sliding glass door is very difficult to open. which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
12/31/2024
Plan of Correction
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2
3
4
On or before due date, the licensee shall send proof to LPA Sampair that repairs to those items have been completed.
Type B
Section Cited
CCR
87412(g)
Personnel Records
(g) All personnel records shall be maintained at the facility.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above for files missing for staff member working as administrator, Nenita Williams, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
12/31/2024
Plan of Correction
1
2
3
4
On or before the due date, the licensee shall send proof to LPA Sampair that a copy of Ms. Williams files have been placed at 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) 529-9416
LICENSING EVALUATOR NAME:
James Sampair
TELEPHONE:
(510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
12/24/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/24/2024
LIC809
(FAS) - (06/04)
Page:
4
of
6
Document Has Been Signed on
12/24/2024 06:17 PM
- It Cannot Be Edited
Created By:
James Sampair
On
12/24/2024
at
05:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
,
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:
12/24/2024
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
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 2 of 2 new staff records reviewed contained no proof of dementia training in 2024, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
12/31/2024
Plan of Correction
1
2
3
4
On or before the due date the licensee shall send proof to LPA Sampair that the required training has been provided to the staff members.
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) 529-9416
LICENSING EVALUATOR NAME:
James Sampair
TELEPHONE:
(510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
12/24/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/24/2024
LIC809
(FAS) - (06/04)
Page:
5
of
6
Document Has Been Signed on
12/24/2024 06:17 PM
- It Cannot Be Edited
Created By:
James Sampair
On
12/24/2024
at
05:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
,
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:
12/24/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.69(a)(2)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 2 of 2 new staff show no proof of training in their files, which posesa potential health, safety or personal rights risk to persons in care.
POC Due Date:
12/31/2024
Plan of Correction
1
2
3
4
On or before the due date the licensee shall send proof to LPA Sampair that the required training has been provided to the staff members.
Type B
Section Cited
CCR
87506(b)
87506 Resident Records
(b) Each resident’s record shall contain at least the following information:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in resident records that were missing appraisal needs and service care plans, pre-appraisals, and admission agreements, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
12/31/2024
Plan of Correction
1
2
3
4
On or before the due date the licensee shall send proof to LPA Sampair that all of the above missing records have been acquired and placed in resident files.
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) 529-9416
LICENSING EVALUATOR NAME:
James Sampair
TELEPHONE:
(510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
12/24/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/24/2024
LIC809
(FAS) - (06/04)
Page:
6
of
6