<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804051
Report Date: 09/12/2024
Date Signed: 09/12/2024 01:05:56 PM

Document Has Been Signed on 09/12/2024 01:05 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:PARADIGM SAN FRANCISCO YOUNG ADULTFACILITY NUMBER:
216804051
ADMINISTRATOR/
DIRECTOR:		GUYOT, MELISSAFACILITY TYPE:
772
ADDRESS:46 ARGUELLO CIRCLETELEPHONE:
(310) 457-6300
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY: 6CENSUS: 5DATE:
09/12/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Staff Member, Hugo Vega-Interiano, and Program Director, Adrian Fuentes TIME VISIT/
INSPECTION COMPLETED:
12:40 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 9:30AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Required 1 year visit and met with Staff Member, Hugo Vega-Interiano. Program Director, Adrian Fuentes, arrived during visit at approximately 9:55AM. Facility is a Short Term Social Rehabilitation home that provides care and assistance to Adults with Mental Health diagnoses. Facility has an approved fire clearance and capacity for 6 Ambulatory Clients. Upon arrival, LPA was informed that there were currently 5 Clients in care and 3 staff members on-site.

At approximately 9:45AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. LPA reviewed staff and client files, and client medications. Facility does not manage P&I monies for clients. Staff Files were all found to be well organized, thorough and contained the required documentation. During client file review, LPA observed that 3 of 5 clients did not have a negative TB test on file (deficiency cited, see LIC809D, regulation 81069(f)(1)). Medication was centrally stored and secure.

LPA requested the following documents to update facility file:
  • Designation of Facility Responsibility (LIC 308)
  • Updated 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 10/12/2024.

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

Exit interview conducted. Copy of report, LIC809D, Plan of Corrections, and Appeal Rights discussed and provided to Program Director. Signature on form confirms receipt of documents.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2024
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 2
Document Has Been Signed on 09/12/2024 01:05 PM - It Cannot Be Edited


Created By: Caitlynn Felias On 09/12/2024 at 12:20 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: 09/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
81069(f)(1)
Client Medical Assessments
(f) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/ infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, Licensee did not comply with the section cited above. LPA observed that 3 of 5 clients did not have proof of negative tb test on file. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/13/2024
Plan of Correction
1
2
3
4
Licensee to submit a written plan outlining how they will ensure Negative TB tests are on file by POC due date of 09/13/2024. Licensee to also submit proof of negative TB tests to CCL when available.
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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2