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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803887
Report Date: 10/08/2021
Date Signed: 10/11/2021 09:41:26 AM

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: 2DATE:
10/08/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Aleli Gabayan - Licensee/AdministratorTIME COMPLETED:
09:00 AM
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Licensing Program Analysts (LPA) Fernandes-Goes conducted an unannounced Case Management Health Checks inspection to this facility and was welcome by Licensee/Administrator Aleli Gabayan. Facility has 2 residents with both under hospice care at this time.

Licensee contacted Department regarding residents being bedridden on 9/20/2021. During this visit LPA reviewed records for residents in care and learned that resident R1 & R2 are under hospice care and LIC 602 - medical assessment for both states that they are non-ambulatory at this time.
At this time there is no need for a new fire clearance.

There were no deficiencies cited at this time.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021
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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