157206732-6-12-2023-24-AS-AWAN-CSQSNC-20230612140119

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 157206732
Report Date: 06/12/2023
Date Signed: 06/12/2023 02:01:38 PM

Document Has Been Signed on 06/12/2023 02:01 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, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME:	PARADISE GARDENS		FACILITY NUMBER:	157206732
ADMINISTRATOR:	DIANA ELLIS		FACILITY TYPE:	740
ADDRESS:	15318 LILA ROSE CT.		TELEPHONE:	(661) 829-1531
CITY:	BAKERSFIELD	STATE: CA	ZIP CODE:	93314
CAPACITY:	6	CENSUS:	DATE:	06/12/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:26 AM
MET WITH:	Facility Staff, Bobbie Arnold		TIME COMPLETED:	02:12 PM

NARRATIVE

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On 06/12/2023, Licensing Program Analyst (LPA) Walton arrvied unannounced to conduct an annual inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator, Diana Ellis. Administrator has a previously scheduled appointment. LPA received verbal permission to meet with Facility Staff Bobbie Arnold

LPA conducted a tour inside and outside of facility. Facility observed to be clean, odor free and at a comfortable temperature. Common areas were furnished well with adequate seating and lighting available. Resident rooms appeared clean and had required furnishings. LPA observed an adequate supply of linen. Resident bathrooms were properly equipped with securely fastened grab bars in toilet and tub/shower areas, non-skid mats were observed. Hot water measured at 115.3 degrees F. Kitchen toured, appeared clean, observed a 7-day supply of non-perishable and 2-day supply of perishable food. Exterior tour conducted, all exits open and free of obstructions. Side gate was observed to be self-latching.

Fire extinguisher serviced on 12/12/2022. Smoke detectors and carbon monoxide detectors observed operational during today’s inspection. Last fire drill conducted 05/2023. All cleaning supplies are locked in a secured cabinet in the laundry room.

LPA reviewed staff and client records. Resident and staff records observed to missing documents. LPA observed an appraisal / Care Plan for 2 out of 6 residents in care. Medications reviewed and observed to have original labels and be administered as prescribed.

A deficiency is being cited in accordance to California Code of Regulations, Title 22, Division 6 on the attached 809D. CONTINUED TO 809C.

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria Walton	TELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2023

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, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: PARADISE GARDENS	FACILITY NUMBER: 157206732
	VISIT DATE: 06/12/2023

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LPA is requesting the following documents be submitted to the Fresno CCL office by 06/26/2023:

· LIC 308 Designation of Facility Responsibility
· -as applicable: LIC 309 Administrative Organization
· -as applicable: LIC 400 Affidavit Regarding Client/Resident Cash Resources
· -as applicable: LIC 402 Surety Bond
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan For Residential Care Facilities For The Elderly
· LIC 9020 Register of Facility Clients/Residents
· Copy of current Liability Insurance

Exit interview conducted. A plan of correction was reviewed and developed with facility staff. A copy of this report and appeal rights were discussed and provided to Facility Staff, Bobbie Arnold, whose signature on this form confirms receipt of this document.

As an operator of a Community Care Licensed facility it is your responsibility to be aware of and in compliance with all regulations, including Chaptered Legislation. Go to www.ccld.ca.gov to stay updated and informed

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria Walton	TELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/12/2023 02:01 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, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: PARADISE GARDENS	FACILITY NUMBER: 157206732
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87457(c)

Pre-Admission Appraisal

(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in out of 4 out of 6 persons who did not have appraisal of his/her individual service needs which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/12/2023
	Plan of Correction
1 2 3 4	Licensee agrees to update resident records to incldue an appraisal of his/her individual service needs by the POC due date. LPA will return at a later date to verify documents are in the facility file.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Melinda Hoffmann	TELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria Walton	TELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2023

LIC809 (FAS) - (06/04)

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