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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700651
Report Date: 07/21/2021
Date Signed: 07/21/2021 03:24:18 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:
07/21/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Angelita DayoanTIME COMPLETED:
03:30 PM
NARRATIVE
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On 7-21-21 Licensing Program Analysts (LPA)s Hubbard and Yang attempted to enter into the physical plant of the facility and observed S1 Albert Lopez sleeping on the couch not supervising the residents in care. LPAs observed no other staff present to supervise the residents in care.

Administrator stated,

"All staff are to be awake on the clock. Staff can only take a nap if another staff is present to supervise. My son Karl was supposed to be present."

The following deficiencies were observed and cited on the following 809D pursuant to title 22 rules and regulations, health and safety code.

Appeal rights were printed and given to facility administrator.

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

DATE: 07/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021
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 2
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: 07/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/28/2021
Section Cited

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Care & Supervison
85605(b) (Zero Tolerance) The licensee shall employ staff as necessary to ensure provision of care and supervision to meet client needs.

This was not met as evidence by:
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Licensee did not ensure staff were awake during shift. LPAs observed one staff present in the facility sleep on the couch with persons in care which poses an immediate health, safety and personal rights risk to persons in care.
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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: 07/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2