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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700651
Report Date: 10/18/2022
Date Signed: 10/18/2022 10:18:41 AM


Document Has Been Signed on 10/18/2022 10:18 AM - 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, 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: 4DATE:
10/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Rosario Reyes - House ManagerTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Ruth Wallace arrived unannounced to conduct a Required 1 Year Annual Inspection Visit. LPA was allowed entry into the home that will be licensed for a capacity of 6 Non-ambulatory residents ages 60 and above of which 4 may receive hospice care services. LPA explained purpose of today's visit with house manager.
Administrator certificate expires . The facility is fire cleared for 6 non-ambulatory and bedroom #5 is to be used as a staff room.

LPA and house manager toured and inspected the physical plant inside and outside to ensure there are no health and safety concerns. LPA observed the kitchen area, dining area, bedrooms, bathroom, storage areas, and laundry rooms. LPA observed knives to be locked. LPA observed required furniture, and lighting throughout the facility. The temperature inside the facility measured at 74.0*F which is within the required range of 68-85*F. The hot water temperature was measured 108.4*F which is within the required range of 105-120*F. LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. The first aid kit included supplies such as sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA observed centrally stored medications area to be locked and inaccessible to residents. LPA observed the fire extinguisher(s) which were inspected on 11/23/2021, smoke and carbon monoxide detector(s) in the home. Fire Drill conducted 9/2/22. The facility has central heating and air.
LPA reviewed 2 Staff and 2 Resident files that were locked and readily available for review. Staff had current first aid/CPR certificates.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations were observed during this visit. Exit interview held with house manager and a copy of report given.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2022
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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