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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201261
Report Date: 06/09/2023
Date Signed: 06/09/2023 12:49:11 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 CAREFACILITY NUMBER:
079201261
ADMINISTRATOR:SAYSON, DENNISFACILITY TYPE:
740
ADDRESS:836 SAN SIMEON DRIVETELEPHONE:
(619) 565-7333
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY:6CENSUS: 3DATE:
06/09/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:48 AM
MET WITH:Dennis Sayson, LicenseeTIME COMPLETED:
01:00 PM
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On 06/09/2023 at 8:48 am Licensing Program Analyst (LPA) J. Clancy-Czuleger arrived unannounced to conduct a change of ownership pre licensing visit. LPA met with Dennis Sayson, Licensee and explained the purpose of the visit.

LPA inspected the facility inside out. There is no body of water. Physical plant is consistent with the facility sketch received by Central Application Bureau (CAB) and approved by the fire department. LPA inspected the living room, dining area, kitchen, bedrooms, hallways, bathrooms, side and backyards. Bedrooms were observed appropriately furnished with adequate lighting and drawers. Facility has sufficient towels, extra bed sheets and comforters. Equipment and supplies for residents' personal hygiene are available and on site. Dinner and silver wares were observed sufficient for residents' use. Food supplies checked and observed good for seven days of non-perishables. Facility was observed equipped with refrigerator, microwave, dishwasher, washer and dryer. Cabinet for knives, cleaning supplies, and central storage for medications were observed with locks. Activity supplies were available. Outdoor activity space was observed furnished with tables, chairs and shade.

Fire extinguishers were observed fully charge and tags showed serviced December, 02, 2022. The two-in-one carbon monoxide and smoke detector tested and observed functional.

Continued on 809-C page...
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)
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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
FACILITY NUMBER: 079201261
VISIT DATE: 06/09/2023
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...Continued from 809


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


Upon receipt of the proof of corrections for the 4 items above, LPA J Clancy-Czuleger will inform CAB.

A exit interview was conducted, and a copy of this report has been provided. Accordingly, LPA will submit a copy of this facility evaluation report to CAB for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.
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
LIC809 (FAS) - (06/04)
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