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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700843
Report Date: 09/06/2023
Date Signed: 09/06/2023 03:49:57 PM


Document Has Been Signed on 09/06/2023 03:49 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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:PADUA ASSISTED LIVING 2FACILITY NUMBER:
342700843
ADMINISTRATOR:DAYOAN, ANGELITAFACILITY TYPE:
740
ADDRESS:2929 BABSON DRIVETELEPHONE:
(279) 333-7621
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:6CENSUS: 5DATE:
09/06/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Angelita DayoanTIME COMPLETED:
03:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit. LPA Moleski met with Angelita Dayoan and explained the purpose of the visit.

LPA Moleski observed a large, purple bruise on a resident's (R1) cheek and around the eye. LPA Moleski interviewed two staff members (S1-S2), who said the resident fell on Monday, August 28, 2023. S1 said R1's family members were notified of the fall. S1 said R1's medications were recently changed, and she has been dizzy as a result. S1 said R1 was not taken to a hospital afterward. S1 was present during the fall, according to S1. LPA Moleski interviewed R1 and asked what happened to her face. R1 said she didn't know.

LPA Moleski reviewed a handwritten narrative written by S1. The narrative described R1 bumping her forehead. According to the narrative, R1's family and Dayoan were notified. LPA Moleski did not receive this handwritten narrative or any other incident report within seven days.

This facility is being cited per 22 CCR Section 87211(a)(1)(D). A civil penalty is being assessed due to repeat violations. An exit interview was held with Dayoan. Appeal rights and a copy of this report were left with Dayoan.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2023
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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Document Has Been Signed on 09/06/2023 03:49 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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: PADUA ASSISTED LIVING 2
FACILITY NUMBER: 342700843

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/13/2023
Section Cited
CCR
87211(a)(1)(D)

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Reporting Requirements: "(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:

(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.

(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident."

This requirement was not met as evicenced by:
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Licensee agrees to conduct a staff training regarding reporting requirements by the POC due date. Licensee further agrees to send a sign-in sheet to LPA Moleski.
vincent.moleski@dss.ca.gov
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Based on observation and interviews, a resident suffered injuries after a fall on Monday, August 28, 2023, and an incident report was not sent to licensing within seven days, as required, which poses a potential health and safety risk.
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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: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2023
LIC809 (FAS) - (06/04)
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