216804051-5-12-2023-21-AS-CFES-CRRW4F-20230512165727

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216804051
Report Date: 05/12/2023
Date Signed: 05/12/2023 04:57:38 PM

Document Has Been Signed on 05/12/2023 04:57 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:	05/12/2023
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	12:50 PM
MET WITH:	Program Director, Jordyn Bonanni		TIME COMPLETED:	05:15 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 12:50PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct an Annual Continuation Visit and met with Program Director, Jordyn Bonanni. Administrator, Melissa Guyot, was available by telephone. During visit, LPA discovered that Staff Member 1 (S1) was not fingerprint cleared or associated to the facility (This deficiency has been cited, see Regulation 81019(e)).LPA also discovered that Staff Member 2 (S2) and Staff Member 3 (S3) were fingerprint cleared, but not associated to the facility as required. LPA contacted the Regional Office and confirmed the fingerprint clearance and association statuses of S1, S2, and S3 to the facility. S1 was informed of their status and they immediately left the premises. Facility confirmed that S1, S2, and S3 were not associated to the facility and sent the association paperwork to the Regional Office today, 05/12/2023. LPA confirmed with the Regional Office that the paperwork had been received. Administrator understands that S1 cannot be on the premises of the facility until they have been properly fingerprint cleared and associated to the facility as required. LPA conducted interviews and a walk through of the facility. LPA requested the following documents to update facility file: Designation of Facility Responsibility (LIC 308) Emergency Disaster Plan (LIC 610D) Updated Personnel Report (LIC 500) Register of Clients/Residents (LIC 9020) Documents to update facility file to be submitted to Community Care Licensing (CCL) by due date of Monday, 06/12/2023. Continued on LIC809C

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

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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Document Has Been Signed on 05/12/2023 04:57 PM - It Cannot Be Edited

Created By: Caitlynn Felias On 05/12/2023 at 03:12 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: 05/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

81019(e)

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code section 1522 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department; or (2) Request a transfer of a criminal record clearance as specified in Section 81019(f); or (3) Request and be approved for a transfer of a criminal record exemption, as specified in Section 81019.1(s), unless, upon request for the transfer, the Department permits the individual to be employed, reside or be present at the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on Record Review and Observations made, Licensee did not ensure that staff member (S1) had the proper background clearance needed to provide care at the facility. This poses an immediate health and safety risk to clients in care.
	POC Due Date: 05/13/2023
	Plan of Correction
1 2 3 4	Licensee to ensure that individuals subject to a criminal record review receive proper clearance and are associated to facility per Title 22 regulations. Licensee to submit a detailed step by step plan for how they will ensure fingerprint clearance and association is complete for an employee prior to them working. Plan to be submitted by POC due dateof Saturday, 05/13/2023.

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: 05/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

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: 05/12/2023

NARRATIVE

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Continued from LIC809

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.

***An immediate civil penalty in the total amount of $100.00 has been issued for a lack of criminal
record clearance as required for S1 (See LIC 421BG).

**Administrator understands that a civil penalty is not being issued today for S2 and S3 because their association paperwork has been received by the Regional Office to be processed.**

Exit interview conducted. Plan of Corrections reviewed and developed with Administrator. Copy of report, LIC
809D, LIC421BG, 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: 05/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

LIC809 (FAS) - (06/04)

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