216804131-5-21-2024-21-AS-CFES-D5GRTG-20240521131816

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216804131
Report Date: 05/21/2024
Date Signed: 05/21/2024 01:18:28 PM

Document Has Been Signed on 05/21/2024 01:18 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 MARINA		FACILITY NUMBER:	216804131
ADMINISTRATOR/ DIRECTOR:	GUYOT, MELISSA		FACILITY TYPE:	772
ADDRESS:	135 MARINA BLVD		TELEPHONE:	(310) 457-6300
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94901
CAPACITY: 6		CENSUS: 4	DATE:	05/21/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:10 AM
MET WITH:	Program Director, Adrian Fuentes		TIME VISIT/ INSPECTION COMPLETED:	01:25 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 9:10AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 year visit. Program Director, Adrian Fuentes arrived during visit at approximately 9:35AM. 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 four Clients in care with all clients out of the community attending an activity and 2 staff members on-site. At approximately 9:45AM, LPA reviewed the Facility's Staff Roster and found that one staff member (S1) was not background cleared or associated to the facility per regulation (this deficiency has been cited, see LIC809D, regulation 81019(e)). Program Director immediately informed S1 to leave the premises. LPA conducted a walk-through of the facility with Program Director and observed the following: Facility is a one story home with 2 single bedrooms, 2 shared bedrooms, 4 bathrooms, an office space, and common areas. Facility has a swimming pool on site. Per conversation with Program Director, if clients want to use the swimming pool, there is at least one staff member supervising. Facility was clean and at a comfortable temperature with all exits free from obstruction. Facility has an Infection Control Plan on file. Bathrooms were equipped with necessary grab bars, and non-slip mats were present. Toxins were secure and inaccessible to clients. 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. There was a sufficient supply of perishable foods as required by Title 22 Regulations. Per Program Director, the facility has their meals delivered from an off-site location. LPA and Program Director discussed having at least 7 days of non-perishable foods available for clients (see LIC9102, Technical Advisory, Regulation 81076(d)(1). Hot water temperatures for all sinks in facility were observed to be outside of Title 22 regulations of 105 to 120 degrees Fahrenheit, measuring at temperatures between 127F and 135F. LPA observed that all sinks had appropriate signs indicating that the water has temperatures that exceed 125F or higher, per regulation 81088(e)(2). Facility's fire extinguishers were last inspected May 2024. Facility's last emergency/disaster drill was conducted December 2023 (See LIC9102, Technical Violation, Health and Safety Code 1565(c)). LPA reviewed staff and client files, and client medications. Facility does not manage P&I monies for clients. All Files were all found to be well organized, thorough and contained the required documentation. Medication was centrally stored and secure. Continued on LIC809C

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 MARINA	FACILITY NUMBER: 216804131
	VISIT DATE: 05/21/2024

NARRATIVE

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Continued from LIC809

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 06/21/2024.

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.

**An Immediate Civil Penalty in the total amount of $100 is being assessed for a lack of criminal

record clearance as required for S1 (See LIC421BG).**

Exit interview conducted. Copy of report, LIC809D, LIC421BG, LIC811 (Confidential Names), 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: 05/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/21/2024 01:18 PM - It Cannot Be Edited

Created By: Caitlynn Felias On 05/21/2024 at 12:46 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 MARINA	FACILITY NUMBER: 216804131
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

81019(e)

Criminal Record Clearance

(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: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations made and records reviewed, the Licensee did not comply with the section cited above. Licensee did not ensure that S1 was background cleared and associated to facility per regulation. This poses an immediate health, safety or personal rights risk to clients in care.
	POC Due Date: 05/22/2024
	Plan of Correction
1 2 3 4	Licensee to submit a written plan outlining their background clearance and association process to ensure compliance with Title 22 regulations by POC due date of 05/22/2024.

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: 05/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

LIC809 (FAS) - (06/04)

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