Community Care Licensing

SUPERVISOR'S NAME: Kristin Heffernan TELEPHONE: (818) 596-4493 LICENSING EVALUATOR NAME: Christine Yee TELEPHONE: (747) 230-3890 LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2024

Document Has Been Signed on 02/15/2024 05:16 PM - It Cannot Be Edited

FACILITY NAME: PARADISE IN THE VALLEY LLC	FACILITY NUMBER: 197609982
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/15/2024

Type B

Section Cited

CCR

87411(f)

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. 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 4 out of 6 staff files reviewed -Myrna Wharf, Abriiana Thomas, Vhanisha Mercado, Evelyn Pena , the files did not contain evidence of a health screen and the results of a TB test and 1 out of 6 files had the results of a TB test and no health screen - Henry Sta Maria, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/22/2024
	Plan of Correction
1 2 3 4	The Licensee shall ensure that all staff submit evidence of good physical health and results of a TB test no later than 7 days after employment or licensure. The documents must be maintained in the Staff's file. Licensee will review all staff files to ensure that all staff have received a health screen with the results of a TB test or take steps to obtain evidence of a health screen and results of a TB test for all staff by 2/22/24. Submit signed statement that all files were reviewed and contain the required health screen and TB test

SUPERVISOR'S NAME: Kristin Heffernan TELEPHONE: (818) 596-4493 LICENSING EVALUATOR NAME: Christine Yee TELEPHONE: (747) 230-3890 LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2024

Document Has Been Signed on 02/15/2024 05:16 PM - It Cannot Be Edited

FACILITY NAME: PARADISE IN THE VALLEY LLC	FACILITY NUMBER: 197609982
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/15/2024

Type B

Section Cited

CCR

87412(a-h)

87412 Personnel Records a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: ........ 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 6 out 6 staff files reviewed all 6 files were missing evidence of trainings, health screens, Criminal Record statements, Employee rights, evidence of live scan....., which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/22/2024
	Plan of Correction
1 2 3 4	Licensee will review Title 22, Section 87412 Personnel Records to ensure that all the information/documents required by that section is contained in all Staff files. Licensee will provide a signed written statement indicating that the section was read and all the required documents have been obtained and are in the staff files by 2/22/24.

Section Cited

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

SUPERVISOR'S NAME: Kristin Heffernan TELEPHONE: (818) 596-4493 LICENSING EVALUATOR NAME: Christine Yee TELEPHONE: (747) 230-3890 LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2024