079200829-2-9-2023-15-AS-LAWN-CNW7CU-20230209203320

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200829
Report Date: 02/09/2023
Date Signed: 02/09/2023 08:33:30 PM

Document Has Been Signed on 02/09/2023 08:33 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	PARADISE VILLA SENIOR CARE II		FACILITY NUMBER:	079200829
ADMINISTRATOR:	DOLO, KONAH		FACILITY TYPE:	740
ADDRESS:	10 SHEILA CT		TELEPHONE:	(925) 262-9476
CITY:	PLEASANT HILL	STATE: CA	ZIP CODE:	94523
CAPACITY: 6		CENSUS:	DATE:	02/09/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:26 PM
MET WITH:	Elizabeth Ulloa, Caregiver		TIME COMPLETED:	06:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 02/09/23 at 3:26 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Caregiver, Elizabeth Ulloa, and explained the purpose of the visit. The Licensee/Administrator Konah Dolo arrived approximately at 3:49 PM. The facility’s fire clearance was approved for 6. . LPA toured facility with Konah including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 5 total bedrooms which 5 bedrooms are occupied by the residents. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 74 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 154 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 06/11/2021. First aid kit was observed to be complete. At 4:30 PM, LPA reviewed 3 residents records. At 4:40 PM, LPA reviewed 2 staff records and 2 of 2 have current first aid training and associated to the facility.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023

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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: PARADISE VILLA SENIOR CARE II	FACILITY NUMBER: 079200829
	VISIT DATE: 02/09/2023

NARRATIVE

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Continued from LIC 809

The following deficiencies observed during the visit:

At 4:07 PM LPA observed, car battery, electric plug, lamp, boxes, paint cans (BEHR),
At 4:08 PM, LPA observed, excess debris/garbage bags at the side of garage, wood planks, broken gated fence at the back yard
At 4:09 PM, LPA observed, 3 mattresses outside, bed frames, patio swing chairs, more wood planks on the other side of the house.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 02/16/2023:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Current Administrator’s Certificate
Facility Sketch
Covid-19 Mitigation Plan
Monkeypox Addendum

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/09/2023 08:33 PM - It Cannot Be Edited

Created By: Lori Alexander-Washington On 02/09/2023 at 04:57 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 VILLA SENIOR CARE II	FACILITY NUMBER: 079200829
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employess 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 by having car battery,electric cord, lamp, boxes, paint cans, bikes, debris, broken gated fence, plywood, wood planks, mattresses, patio furniture, beds accessible to clients in care which poses potential health and safety risk to persons in care.
	POC Due Date: 03/09/2023
	Plan of Correction
1 2 3 4	Administrator will remove all items listed above from the outside front and backyard area. Administrator can e-mail pictures to CCLD by POC due date.

Type B

Section Cited

CCR

87293

All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. 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 which poses a potential health and safety risk to persons in care.
	POC Due Date: 02/23/2023
	Plan of Correction
1 2 3 4	Administrator will get fire extinguisher updated and send a email or fax a copy of a picture of the receipt to CCLD by POC 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:

Bennett Fong

LICENSING EVALUATOR NAME:

Lori Alexander-Washington

LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023

LIC809 (FAS) - (06/04)

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