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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200312
Report Date: 08/07/2024
Date Signed: 08/07/2024 09:38:22 AM


Document Has Been Signed on 08/07/2024 09:38 AM - 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: 4DATE:
08/07/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Dennis Sayson, AdministratorTIME COMPLETED:
10:00 AM
NARRATIVE
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On 08/07/2024 at 08:45 AM Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to conduct a Case Management. LPA met with Dennis Sayson, Administrator.

While at the facility LPA J. Clancy-Czuleger conducting a complaint investigation (15-AS-20240805132024) on 08/07/2024, LPA was informed that the facility was unaware that they needed to submit incident reports for outbreaks at the facility. S1 stated that they had an outbreak of scabies in May 2024, and a second outbreak in August 2024 that were not reported to CCLD.

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. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024
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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Document Has Been Signed on 08/07/2024 09:38 AM - 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: 08/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/21/2024
Section Cited
CCR
87211(a)(2)

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Reporting Requirements. Within 24 hours the licensee shall notify the licensing agency... if an epidemic outbreak, poisoning, ... or health of residents, personnel or visitors occurs.
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Administrator to read the Regulations.
In addition, administrator to submit a copy of LIC624 for R1 by 8/21/2024
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This requirement was not met as evidenced by S1 stating that they did not know they needed to report outbreaks
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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: 08/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024
LIC809 (FAS) - (06/04)
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