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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700651
Report Date: 07/22/2021
Date Signed: 07/22/2021 01:04:53 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:PADUA ASSISTED LIVINGFACILITY NUMBER:
342700651
ADMINISTRATOR:PADUA, NICHOLASFACILITY TYPE:
740
ADDRESS:7019 MCGILL COURTTELEPHONE:
(916) 647-3483
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:6CENSUS: 6DATE:
07/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Angelita DayoanTIME COMPLETED:
01:00 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
On 7-22-21 at 10:00am Licensing Program Analyst(s) (LPA) Tirzah Hubbard and Avelina Martinez arrived unannounced to conduct a Required Annual 1 Year inspection. LPAs met with Angelita Dayoan, Administrator and stated the purpose of today’s visit. LPAs was allowed entry into the facility that is licensed to serve a total capacity of 6 clients. 1 Hospice Waiver and 1 Home health.

LPA's interacted with a random number of residents during this visit.
The physical plant was toured inside and outside to ensure the safety of the residents.

LPA’s observed when entering the facility 1 Staff present during the visit. LPA’s observed the physical plant of the facility in moderate condition. LPA observed the flooring of the facility in good condition.
LPA's observed the facility does not conduct fire drills monthly. All staff need training with medication and persons with Dementia. LPAs observed the facility inadequate staffing for persons with dementia. LPAs observed medication not stored and locked away inaccessible to persons in care. LPAs observed medication in food pantry accessible to residents. LPAs observed medication not logged into Medication Administration record (MARS). LPAs interviewed S1 to discuss medication storage and MARS daily logs.

S1 stated,
" I am the only staff here. I did not log medication into MARS because I needed to start breakfast for the residents. I am doing multiple task at once. I placed the medication in the food pantry to help the residents because Kar left the facility."

The temperature inside the facility was measured at 78 *F which is within the required range of 68 degrees F (20 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat the maximum shall be 30 degrees F (16.6 degrees C) less than the outside temperature.

SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tirzah HubbardTELEPHONE: 559-365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021
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 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PADUA ASSISTED LIVING
FACILITY NUMBER: 342700651
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(b)
Storage Space
(b) Medicines shall be stored as specified in Section 87465(c) and separately from other items specified in (a) above.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interviews, the licensee did not comply with the section cited above. LPAs observed medications stored in food pantry, in freezer next to meat, and not logged into MARS which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2021
Plan of Correction
1
2
3
4
Licensee will administer Medication training to all staff and remove medications from refregerator.
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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tirzah HubbardTELEPHONE: 559-365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2021
LIC809 (FAS) - (06/04)
Page: 2 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PADUA ASSISTED LIVING
FACILITY NUMBER: 342700651
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(a)
Personnel Requirements - General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interviews, the licensee did not comply with the section cited above. LPAs observed 1 staff present stating medication was not stored in MARS due to not having help. S1 stated medication was stored in food pantry because I needed to prepare breakfast which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2021
Plan of Correction
1
2
3
4
Licensee will ensure the facility is fully staffed at all times for persons with dementia.
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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tirzah HubbardTELEPHONE: 559-365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2021
LIC809 (FAS) - (06/04)
Page: 3 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PADUA ASSISTED LIVING
FACILITY NUMBER: 342700651
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(28)
General Food Service Requirements
(b) The following food service requirements shall apply: (28) All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in ensuring all food is properly labled and not containing freezer burn on meat which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2021
Plan of Correction
1
2
3
4
Licensee as removed all freezer burned meat from all freezers and have properly labeled food.
Type A
Section Cited
CCR
87705(c)(4)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident's physical, social, emotional, safety and health care needs as identified in his/her current appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation there was 1 staff in the facility at the time of visit on 7-22-21 at 10:00am, the licensee did not comply with the section cited above in ensuring the facility being fully staffed for persons with dementia which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2021
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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tirzah HubbardTELEPHONE: 559-365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2021
LIC809 (FAS) - (06/04)
Page: 4 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PADUA ASSISTED LIVING
FACILITY NUMBER: 342700651
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. LPAs observed over the counter medication on the kitchen counter which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2021
Plan of Correction
1
2
3
4
Licensee has removed medication from counter.
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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tirzah HubbardTELEPHONE: 559-365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2021
LIC809 (FAS) - (06/04)
Page: 5 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PADUA ASSISTED LIVING
FACILITY NUMBER: 342700651
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(4)
Other Provisions
(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (4) Ensure that the facility is clean, safe, sanitary, and in good repair at all times.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. LPAs observed cigerette buds in the backyard, garage containing old mattresses, and piles of trash in backyard which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2021
Plan of Correction
1
2
3
4

Licensee has contacted the city for trash pick up.
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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tirzah HubbardTELEPHONE: 559-365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2021
LIC809 (FAS) - (06/04)
Page: 6 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: PADUA ASSISTED LIVING
FACILITY NUMBER: 342700651
VISIT DATE: 07/22/2021
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
26
27
28
29
30
31
32
The hot water was measured at 116 *F which is not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C) as per Title 22 regulations.

LPAs observed in garage are old mattresses and chairs. LPAs observed cigarette buds located in the backyard on the side of the facility next to piles of trash. LPAs observed refrigerated medication stored in the garage freezer with frozen meat.

The first aid kit was found in compliance containing at least the following: a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution.

LPAs Tirzah Hubbard observed a pull alarm system, fire extinguisher(s), smoke and carbon monoxide detectors, central heating and air in the facility. LPAs observed the smoke detector located in the kitchen in disrepair and detached from ceiling.

LPAs observed food supplies of staple nonperishable foods were missing and no stored for emergency. There were no perishable foods for a minimum of two days that shall be maintained on the premises at all times. Food in freezer consisted of freezer burn and additional food I zip lock bags were not labeled. The kitchen staff thawed out food over night on the kitchen counter. The sharp objects that are : Knives, forks, and spoons locked away.

Administrator have sent all documents requested In 1 week prior to visit.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies were observed and cited on LIC809 D. Exit interview held, copy of report given on 7-22-21 return visit.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tirzah HubbardTELEPHONE: 559-365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021
LIC809 (FAS) - (06/04)
Page: 7 of 7