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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700651
Report Date: 11/08/2021
Date Signed: 11/23/2021 02:15:35 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: 5DATE:
11/08/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Licensee Angelita DayoanTIME COMPLETED:
12:00 PM
NARRATIVE
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On 11-8-21 Licensing Program Analyst (LPA) Tirzah Hubbard conducted an unannounced case management visit. LPA met with Licensee and Administrator Angelita Dayoan to discuss the deficiencies observed.

LPA Hubbard toured the physical plant of the facility.

On 11-5-21 LPA observed 1 Staff working in the facility without finger print clearance. LPA observed the staff undressing and clothing R1 while Administrator was not present in the facility.

Administrator stated,

" I sent the paper work into CCL by fax on 11-4-2021. Nicole who was the officer of the day stated Robert (S1) can work while the paper work is processing'.

LPA stated,

" I have reviewed the personnel report and guardian and the system shows S1 is not cleared to work in the facility. All documentation has to be provided showing the staff are cleared in order for them to work in the facility. A fax statement does not indicate that the caregiver is cleared to work in the facility."

LPA asked Licensee to ask Staff 1 to leave. The staff can no longer work until cleared.


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: 11/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021
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
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: 11/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
11/16/2021
Section Cited

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87355(b)
Criminal Record Clearance. (b) Prior to the Department issuing a license, the applicant, administrator and any adults other than a client, residing in the facility shall have a criminal record clearance or exemption.
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This is not met by evidence by:
Based on observation and review licensee did not ensure that all staff have fingerprint clearance in order to work in the facility which poses an immediate health, safety, and personal rights risk for 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: 11/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2021
LIC809 (FAS) - (06/04)
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