216804051-5-9-2023-21-AS-CFES-CRNUQY-20230509154754

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216804051
Report Date: 05/09/2023
Date Signed: 05/09/2023 03:48:02 PM

Document Has Been Signed on 05/09/2023 03:48 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:	PARADIGM SAN FRANCISCO YOUNG ADULT		FACILITY NUMBER:	216804051
ADMINISTRATOR:	GUYOT, MELISSA		FACILITY TYPE:	772
ADDRESS:	46 ARGUELLO CIRCLE		TELEPHONE:	(310) 457-6300
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94901
CAPACITY: 6		CENSUS: 2	DATE:	05/09/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Administrator, Melissa Guyot, and Program Director, Jordan Bonanni		TIME COMPLETED:	03:55 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At approximately 9:45AM, Licensing Program Analyst (LPA) Felias, arrived unannounced to conduct a Required 1 Year visit, and met with Administrator, Melissa Guyot, and Program Director, Jordan Bonanni. The Facility is a Social Rehabilitation Facility and provides care and assistance for Adults with Mental Health. The Facility has an approved fire clearance for 6 Ambulatory clients. Upon arrival, LPA was informed that 2 of 2 clients were out of the community attending an activity. At approximately 10:05AM, LPA conducted a walk through of the facility and observed the following: the Facility is a one story home with 2 single bedrooms, 2 shared bedrooms, 2 and 1/2 bathrooms, an office space, and common areas such as a kitchen, living room, and dining room. LPA observed cabinets located in the facility's office space that obtained client medication and sharps. These were locked and inaccessible to clients in care. Facility has a swimming pool on site. LPA observed that the swimming pool has a perimeter fence and was locked at the time of visit. Per conversation with Administrator, the swimming pool is to be locked at all times unless in use. If clients want to use the swimming pool, there will be two staff members supervising. Administrator informed LPA that all staff have their Water Safety Certificates. LPA observed that the facility was clean and at a comfortable temperature with all exits free from obstruction. Bathrooms were equipped with necessary grab bars, and non-slip mats were present. Bathrooms were supplied with paper towels, liquid hand soap, and hand-washing signs. Toxins were secure and inaccessible to clients in care. There was a sufficient supply of hygiene products, paper products, and linens available for client use. Mattress pads were in place or available for client use. Hot water temperatures for all sinks in facility were within Title 22 regulations of 105 to 120 degrees Fahrenheit. Facility has a sufficient amount of perishable and nonperishable foods per regulation. Facility has an adequate supply of kitchen tools. Continued on LIC809C

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: PARADIGM SAN FRANCISCO YOUNG ADULT	FACILITY NUMBER: 216804051
	VISIT DATE: 05/09/2023

NARRATIVE

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Continued from LIC809

Per conversation with Administrator, sharps such as knives are located in a locked box in the kitchen. Only Facility Staff have access to the knives/other sharps.

There is one laundry area in the facility. Toxins and Detergents were observed to be located in a storage area located in the garage. It was observed to be locked and inaccessible. Per conversation with Administrator, if clients want to do their laundry, they ask a staff member for the detergent. The staff member will obtain the detergent from the storage area, and place it into the washing machine for the client.

Per conversation with Administrator, the facility's main exit doors are not equipped with sensors/delayed egress. Clients will always be in the line of sight of Facility staff to ensure their safety.

At approximately 11:00AM, LPA reviewed a sample size of 7 staff files. LPA observed that all staff files were well organized, thorough and contained the required documentation. All Staff had current First Aid/CPR and Water Safety Certificates on file.

At approximately 12:15PM, LPA reviewed 2 of 2 client files. Review of client files revealed that the clients did not have a Medical Assessment or Tuberculosis (TB) Test completed by a Medical Professional prior to move in. (See Technical Advisory Note for Regulation 81069(a)(1) and Regulation 81069(f)(1).)Client files showed that each client self-reported an assessment prior to being admitted into the facility. Administrator understands that a medical assessment and TB test needs to be conducted and on file for current and prospective clients. Administrator showed LPA documentation that the clients have have been scheduled to complete the medical assessments needed.

LPA also found that Client 1 (C1) has cash funds that are kept in the staff's office space. Per conversation with Administrator, these cash funds are for medication co-pays and sometimes for outings (See Technical Advisory Note for Regulation 81026(h)(1)).Review of C1's file shows that they are able to handle their own monetary funds. Administrator understands that every transaction of C1's cash funds are to be documented and signed for to ensure that client money is being properly safeguarded.

Continued on LIC-809C

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: PARADIGM SAN FRANCISCO YOUNG ADULT	FACILITY NUMBER: 216804051
	VISIT DATE: 05/09/2023

NARRATIVE

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Continued from LIC809C

At approximately 1:00PM, LPA reviewed 2 of 2 client medications. All medications were found to be centrally stored and secure.

Facility has an Emergency Disaster Plan in place. Combination Smoke and Carbon Monoxide Detectors were tested and operational. The last Emergency/Fire Drill was conducted April 2023.

During the walk-through, LPA observed 3 of 3 fire extinguishers to be last charged by the Fire Department in December 2021 but were last inspected in April 2023. Per conversation with Administrator, the Facilities Manager inspects the fire extinguishers every month to make sure they are intact and not tampered with. (This deficiency has been cited, Regulation 81020(a), See LIC 809-D.)Administrator understands that fire extinguishers need to be inspected yearly to maintain compliance.

LPA unable to complete the Annual Inspection. Annual Continuation Visit to be conducted at a later date.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC811 (Confidential Names), LIC809D (Deficiency Page), LIC9102 (Technical Advisory Notes), Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/09/2023 03:48 PM - It Cannot Be Edited

Created By: Caitlynn Felias On 05/09/2023 at 03:00 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: PARADIGM SAN FRANCISCO YOUNG ADULT	FACILITY NUMBER: 216804051
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

81020(a)

81020 Fire Clearance (a) A social rehabilitation facility shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal. This requirement is not met as evidenced by: Based on LPA observation, the Licensee did not comply with the section cited above for 3 of 3 fire extinguishers which were shown to be last serviced December 2021. This poses a potential health and safety risk to residents in care.
	Deficient Practice Statement
1 2 3 4
	POC Due Date: 05/19/2023
	Plan of Correction
1 2 3 4	Licensee to contact Fire Department or Fire Safety company to have the fire extinguishers serviced. Licensee to submit copy of invoice/receipt and pictures of newly dated tags by POC date of 05/19/2023.

Section Cited


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

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Kimberley Mota

LICENSING EVALUATOR NAME:

Caitlynn Felias

LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

LIC809 (FAS) - (06/04)

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