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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200312
Report Date: 06/09/2023
Date Signed: 06/09/2023 12:49:57 PM


Document Has Been Signed on 06/09/2023 12:49 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 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: 3DATE:
06/09/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:48 AM
MET WITH:Dennis Sayson, CaregiverTIME COMPLETED:
01:00 PM
NARRATIVE
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On 06/09/23 at 08:48 am, Licensing Program Analyst (LPA) J Clancy-Czuleger arrived unannounced to conduct a Pre-Licensing Inspection for a Change of Ownership (CHOW). LPA was greeted by one Care Staff upon entry and explained the purpose of the visit.

LPA observed the following during the inspection:

Two of the three residents did not have appraisal needs and services plan.


two staff records do not have LIC 508, LIC 501, or employee rights
storage house in back needs new doors, broken concrete around storage outside
incomplete first aid kit

The deficiency was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties


Exit interview conducted and a copy of this report given.

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2023
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 3


Document Has Been Signed on 06/09/2023 12:49 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 VILLA SENIOR CARE, LLC
FACILITY NUMBER: 079200312

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/30/2023
Section Cited
CCR
87303(a)

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(a) The facility shall be clean, safe, sanitary and in good repair at all times...

This requirement is not met as evidenced by:
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The facility agrees to fix the broken doors and remove the broken concrete. Proof of correction will be sent to CCLD by POC date
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Based on observation, the licensee did not comply with the section cited above by having broken doors and broken concrete on/around the outside storage shed
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Type B
06/30/2023
Section Cited
CCR87506(b)(17)(A)

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Each resident’s record shall contain at least the following information (17) Documents and information required by the following: (A)Section 87457, Pre-Admission Appraisal

This requirement is not met as evidenced by:
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The facility agrees to fill out pre-apprasials for two residents, and updated needs and services plan for all of the residents. Proof of correction will be sent to CCLD by POC date
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Based on records review, the licensee did not comply with the section cited above by not having pre-apprasials for two residents, or updated needs and services plan for all of the residents.
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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: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3


Document Has Been Signed on 06/09/2023 12:49 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 VILLA SENIOR CARE, LLC
FACILITY NUMBER: 079200312

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/30/2023
Section Cited
CCR
87412(a)

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(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee

This requirement is not met as evidenced by:
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The facility agrees to fill out pre-apprasials for two residents, and updated needs and services plan for all of the residents. Proof of correction will be sent to CCLD by POC date
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Based on records review, the licensee did not comply with the section by not having LIC 508, LIC 501, or employee rights in the resident records
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Type B
06/30/2023
Section Cited
CCR87465(a)(8)

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 (8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility.

This requirement is not met as evidenced by:
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The facility agrees to complete the first aid kit. Proof of correction will be sent to CCLD by POC date
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Based on observation, the licensee did not comply with the section by not having a complete first aid kit.
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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: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2023
LIC809 (FAS) - (06/04)
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