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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200829
Report Date: 02/28/2025
Date Signed: 02/28/2025 05:15:04 PM

Document Has Been Signed on 02/28/2025 05:15 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 VILLA SENIOR CARE IIFACILITY NUMBER:
079200829
ADMINISTRATOR/
DIRECTOR:		DOLO, KONAHFACILITY TYPE:
740
ADDRESS:10 SHEILA CTTELEPHONE:
(925) 262-9476
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY: 6CENSUS: 5DATE:
02/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Administrator Rahab MungaiTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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On February 28, 2025 at 1:00 PM, Licensing Program Analyst (LPA) James Sampair arrived unannounced to conduct this annual required inspection. The LPA informed Caregiver Elizabeth Ulloa of the purpose for this visit. Administrator Rahab Mungai arrived at approximately 1:30 PM.

The LPA inspected the inside and outside of the facility. The inspection included the kitchen, dining area, living room, bedrooms, bathrooms, garage, and yard. An adequate amount of food supplies were observed, more than the required minimum of 2 days of perishable and 7 days of non-perishable food. The central storage for medications was locked. The cleaning supplies and dangerous objects were stored in locked cabinets.

The Facility has working smoke and carbon monoxide detectors. The staff of the facility conduct disaster / emergency and fire drills on a quarterly basis; records showed that the most recent drill was conducted on December 11, 2024. The fire extinguisher was fully charged and last serviced on March 1, 2024. The indoor temperature was 76.8 degrees Fahrenheit, within the acceptable range. The maximum hot water temperature was 131.3 degrees Fahrenheit, which was not within the acceptable range of 105 to 120 degrees Fahrenheit.

The LPA reviewed 5 resident and 5 staff records.

1 Type-A citation was issued during this inspection.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 02/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/28/2025
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 02/28/2025 05:15 PM - It Cannot Be Edited


Created By: James Sampair On 02/28/2025 at 04:59 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: 02/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. The hot water was measured at 131.3 degrees Fahrenheit, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/01/2025
Plan of Correction
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On or before the due date, the Licensee shall send a statement to LPA Sampair that the temperature has been reduced to the safe range of 105 to 120 degrees Fahrenheit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 Humpal
LICENSING EVALUATOR NAME:James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2025


LIC809 (FAS) - (06/04)
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