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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200312
Report Date: 09/21/2021
Date Signed: 09/21/2021 02:31:12 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 VILLA SENIOR CARE, LLCFACILITY NUMBER:
079200312
ADMINISTRATOR:KONAH DOLOFACILITY TYPE:
740
ADDRESS:836 SAN SIMEON DRIVETELEPHONE:
(925) 483-2595
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY:6CENSUS: 5DATE:
09/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Konah Dolo, AdministratorTIME COMPLETED:
02:45 PM
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On 09/21/21 at 1:30PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an infection control annual inspection and explained the purpose of the visit with administrator. LPA observed 2 staff wearing face masks during visit. LPA observed 3 residents watching TV in the living room while the other 2 residents were resting inside their bedrooms during visit. Facility has a mitigation plan in place dated 02/16/21 to mitigate the spread of COVID-19. LPA discussed the completed mitigation plan (LIC 808) with administrator as well as COVID-19 infection control practices. LPA inspected the facility inside and outside.

One central entry point has been designated for universal entry screening with the station located near the front entrance with visitor's log, hand sanitizer, gloves, face masks and no touch temperature probe. COVID-19 signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette and physical distancing. Facility documents daily temperatures and COVID-19 symptom checks for staff and residents. Pathways were observed to be free of obstruction and fire hazards.

A written Emergency/Disaster plan dated 04/01/21 was posted on the bulletin board in the living room area.

Continued on next page LIC 809-C
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
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 VILLA SENIOR CARE, LLC
FACILITY NUMBER: 079200312
VISIT DATE: 09/21/2021
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Centrally stored medications were locked in kitchen cabinets. Sharp objects were locked in the kitchen drawers. Toxic chemicals were locked stored in the hallway closet. Infection control designated leader is the administrator. All staff and residents have been fully vaccinated since February 2021. There was at least 7 days of nonperishable and 2 days of perishable foods. Emergency food supplies were observed stored in the laundry room area. Facility room temperature was maintained at 73 degrees Fahrenheit. Resident's bedrooms and bathrooms have COVID-19 signages. A certified administrator is on site a minimum of 20 hours a week to oversee proper business operation and compliance with COVID-19 infection control practices. Fire extinguisher was fully charged and last inspected on 07/08/2021. Smoke and Carbon monoxide detectors were operational.

Adequate supplies of PPE were also observed stored in the hallway closet. Facility follows daily cleaning, sanitation of frequently touched common surfaces using Clorox and Lysol disinfectants.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 09/22/2021:
· LIC500- Personnel Report
· LIC308- Designation of Facility Responsibility
· LIC610E- Emergency/Disaster Plan
· Evidence of Liability Insurance & Surety Bond

No deficiencies cited during this visit. Exit interview conducted and a copy of this report provided to administrator.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
LIC809 (FAS) - (06/04)
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