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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803887
Report Date: 07/30/2020
Date Signed: 07/30/2020 03:09:29 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:PARADISE ELDERLY RESIDENTIAL CARE OF MARINFACILITY NUMBER:
216803887
ADMINISTRATOR:GABAYAN, ALELIFACILITY TYPE:
740
ADDRESS:4210 PARADISE DRTELEPHONE:
(415) 650-7793
CITY:TIBURONSTATE: CAZIP CODE:
94920
CAPACITY:4CENSUS: 1DATE:
07/30/2020
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
09:49 AM
MET WITH:Aleli Gabayan (Licensee)TIME COMPLETED:
11:08 AM
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Licensing Program Analyst Cuadra conducted the Post Licensing inspection via video conferencing due to Covid 19 precautions with Licensee, Aleli Gabayan and obtained email address (percmarin@gmail.com) to send LIC809 and requested signed copy to be emailed back to LPA before Monday 8/3/20. There is currently 1 resident in care and Licensee is the only staff at this moment in the facility.

Licensee conducted a walk through via video conferencing and LPA observed that resident rooms were furnished per regulations and two shared full bathrooms were equipped with non-slip floors and mats for safety. Water temperature tested at 111.7 degrees F. Facility has required postings including CCL Complaint Poster, Resident Bill of Rights and Resident Rights. Additional posters regarding proper hand washing, droplet precautions and sanitation pertaining to Covid-19. Facility has a sanitation station set up at the entrance to the facility in order to comply with Covid-19 precautions. Facility are screening staff or essential visitors for symptoms. The facility staff was observed wearing mask during the virtual tour of main entrance, doors, common areas, dining rooms and kitchen area. Trash bins, hand washing station with soap and paper towels were observed. The facility provides assistance with family communication via telephone or video call. Facility has at least two days of perishable and one week of nonperishable foods. Facility has space indoors and outdoors for resident activities. Fire extinguisher was last serviced 3/2020. Carbon Monoxide Detector and smoke detectors were operational. Fire clearance has been approved for 4 non-ambulatory residents by the Marin County Fire Department.

Resident and staff records were reviewed and are current. Staff have an active First Aid/CPR Certificate and annual training was current. New Admission agreements with all residents and physician’s reports were current. Medication is centrally stored and locked in a cabinet. A Centrally Stored Medication Log is maintained. LPA discussed facility's Disaster Preparedness with Licensee including observing their Emergency supplies. Toxins are locked in cabinets. First aid kit fully stacked. LPA reviewed with Licensee PIN 20-23.

No deficiencies cited during this inspection.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2020
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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