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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803887
Report Date: 02/02/2023
Date Signed: 02/02/2023 02:41:15 PM


Document Has Been Signed on 02/02/2023 02:41 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



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: 0DATE:
02/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Aleli Gabayan, AdministratorTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Jill Nakagawa conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with Licensee/Administrator Aleli Gabayan. There were no residents at the time of inspection. The facility has a beautiful view of the Bay; available for residents and their visitors to enjoy, safely and securely.

During facility tour on 02/02/23 with licensee/administrator; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Residents' bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last checked by Fire Marshall on 02/02/23. Sample test of Smoke Detectors & Carbon monoxide detector were found to be operational during this visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations during this visit. Toxins are stored in a locked cabinet inside the laundry area and under kitchen sink. Dangerous items were stored inaccessible to clients. There was a supply of cleaners, hygiene products and paper products available for clients. All residents' bedrooms have lighting & appropriate furnishings. Disaster Drills are conducted quarterly with staff and residents when facility is operating.

Facility has submitted a Mitigation Control Plan which has been approved as well as an Infection Control Plan. Posters have been placed at entrance and throughout the facility. Facility has hand sanitizer available for visitors. Staff and residents have temperature checked daily. Facility has PPE supply stored. Residents’ medications are stored and locked in kitchen cabinet. Facility keeps a 30-day supply of medication for clients. All staff had masks on during this visit. In addition, facility has a designated area for visitors which are being allowed. Residents have virtual and telephone calls available to them to stay in contact with family members and others between in-person visits. Staff have had PPE training as required.

There were no deficiencies at this time. No citations issued.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2023
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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