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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700651
Report Date: 12/20/2022
Date Signed: 12/21/2022 03:40:27 PM


Document Has Been Signed on 12/21/2022 03:40 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
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: 2DATE:
12/20/2022
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Angelita DayoanTIME COMPLETED:
05:00 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
Licensing Program Analyst (LPA) Victoria Brown, Licensing Program Manager (LPM) Stephen Richardson, Regional Manager (RM) Stephenie Doub and Jacqueline Juarez Supervising Governmental Auditor I conducted a meeting via Microsoft Teams on 12/20/22 at 1pm with Licensee Padua Assisted Living Inc, Angelita Dayoan and Nicholas Padua, Administrator to discuss the findings of the Audit investigation, revision of the complaint allegations, and other deficiencies observed.

Regional Manager Stephenie Doub began the meeting by stating the purpose of the meeting. Jacqueline Juarez Supervising Governmental Auditor I then proceeded to review the findings of the Audit Investigation. The items of discussion were:
1. Corporation structure
2. Audit findings
3. Complaint allegations
4. Unlicensed facilities
5. Responsibility of the Licensee/POA duties
6. Incomplete Records
7. Appraisals/Reappraisals
8. Increased Monitoring
9. Resident finances/handling
Community Care Licensing expectations:
-Be familiar with facilities Plan of Operation
-All handling of residents assets/monies shall cease immediately

As a result of the audit and a review of documents submitted, Community Care Licensing (CCL) found that the Licensee relocated R1 from a licensed facility to a location other than a licensed facility. The new location was not a licensed facility to which R1 should be residing based on care and supervision that is needed.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2022
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 4


Document Has Been Signed on 12/21/2022 03:40 PM - It Cannot Be Edited

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: 12/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/21/2022
Section Cited

1
2
3
4
5
6
7
Operation Without a License
An unlicensed facility as defined in Section 87101(u)(2) is in violation of section 1569.10, 1569.44, and/or 1569.45 of the Health and Safety Code unless the facility is exempted from licensure under Section 87107(a). If the facility is alleged to be in violation of section 1569.10 and/or 1569.44 and/or 1569.45 of the Health and Safety Code, the licensing agency shall conduct a site visit and/or evaluation of the facility pursuant to Health and Safety Code section 1569.35.
1
2
3
4
5
6
7
Licensee shall submit a letter of understanding the importance of resident placement in a licensed facility where care and supervision shall be provided. To be faxed by POC due date.
8
9
10
11
12
13
14
This requirement is not met as evidenced by: Licensee knowingly kept R1 at an unlicensed home.
Based on interviews and records review, the licensee did not ensure proper care and supervision services was provided in a licensed facility for R1 in which the licensee was operating.
This posed an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
Type A
12/21/2022
Section Cited

1
2
3
4
5
6
7
False Claims

No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.
1
2
3
4
5
6
7
Licensee shall write a statement of understanding that this regulations shall be upheld at all times. POC to be faxed to CCL by POC due date.
8
9
10
11
12
13
14
This requirement is not met as evidenced by: Licensee stated she had no knowledge of being POA, Trustee, 50% heir to R1s assets
Based on Licensee did not provide truthful information to CCL.
This posed an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
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: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4


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: 12/20/2022
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 Licensee admitted R1 into the facility without completed required documents such as the Pre-appraisal. The Licensee stated she did not have knowledge that she was made the POA, Trustee, or 50% heir for R1's assets. Licensee stated she did not write checks for R1 having R1 to provide a signature. Licensee stated she did not submit an LIC400 Affidavit regarding client/resident Cash resources nor LIC402 Surety Bond to handle or assist residents with their monies. Based on documentation review, the Licensee provided false statements during this meeting.

The preponderance of evidence standards has been met; therefore, the above shall be cited during this visit.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Licensee was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 12/21/2022 03:40 PM - It Cannot Be Edited

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: 12/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/21/2022
Section Cited

1
2
3
4
5
6
7
Resident Records
The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
1
2
3
4
5
6
7
Licensee shall submit a plan on when all residents files are to be reviewed and completed. Submit by fax by POC due date
8
9
10
11
12
13
14
This requirement is not met as evidenced by: Required documents for resident admittance were incomplete
Based on records review, the licensee did not ensure all required documents were completed for R1.
This posed an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
Type A
12/21/2022
Section Cited

1
2
3
4
5
6
7
Bonding
Each application for a license ...shall be accompanied by an affidavit on a form provided by the licensing agency...state whether the applicant/licensee will be entrusted/is entrusted to safeguard or control cash resources of persons and the maximum amount of money to be handled for all persons in any month.
1
2
3
4
5
6
7
Licensee shall cease all handling of monies and assests for residents immediately and submit an LIC400 indicating if the facility will/will not handle cash resources. If so, and LIC402 shall be submitted as well. POC to be fax by POC due date.
8
9
10
11
12
13
14
This requirement is not met as evidenced by: Licensee was assisting R1 w/handling finances.
Based on licensee did not ensure R1s finances was handled by RP
This posed an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
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: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4