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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803887
Report Date: 11/29/2021
Date Signed: 11/30/2021 11:04:27 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: 1DATE:
11/29/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Aleli Gabayan - Licensee/AdministratorTIME COMPLETED:
10:35 AM
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Licensing Program Analyst (LPA) Fernandes-Goes conducted an unannounced case management and met with Aleli Gabayan - Licensee/Administrator. The purpose of the case management visit was to obtain additional information regarding SOC 341 - Suspected Abused report that was submitted to the Department on 10/20/2021 for resident R1.

LPA has asked questions regarding resident R1, requested more information on the incident- see LIC 812, and copy of documentation for staff S1 involved on this incident and resident R1. Licensee/Administrator met with staff S1 right after incident and staff was release from its position. Staff S1 no longer work at this facility since incident.


No deficiencies cited during today’s visit.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2021
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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