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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700843
Report Date: 08/06/2024
Date Signed: 08/06/2024 12:27:07 PM


Document Has Been Signed on 08/06/2024 12:27 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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:
08/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Angelita DayoanTIME COMPLETED:
12:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct an annual inspection. LPA Moleski met with facility administrator Angelita Dayoan and explained the purpose of the visit.

LPA Moleski reviewed five resident files (R1-R5) and three staff files (S1-S3). LPA Moleski observed in R5's file an after-visit summary which stated R5 went to the hospital on 6/25/24 due to abdominal pain, and received a CT scan while there. LPA Moleski observed a handwritten incident report in R5's file regarding the hospital visit, but which was not completed, and did not indicate that it was sent to CCLD. LPA Moleski reviewed email and fax records and observed that no report had been received regarding this incident.

LPA Moleski toured the facility with Dayoan and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 75 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 106 degrees Fahrenheit, which is within the required range of 105 and 120 degrees.

LPA Moleski observed first aid supplies, a fully-charged and up-to-date fire extinguisher, and working carbon monoxide/smoke detectors. LPA Moleski observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Moleski observed a locked cabinet for the storage of medication. LPA Moleski observed locked cabinets for the storage of cleaning solutions and knives.

LPA Moleski interviewed two staff members (S1-S2) and one resident (R1).

This facility is hereby cited per 22 CCR Section 87211(a)(1). 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: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2024
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 08/06/2024 12:27 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: PADUA ASSISTED LIVING 2
FACILITY NUMBER: 342700843

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87211(a)(1)
Reporting Requirements
(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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, a report was not received for an incident which occurred on 6/25/24, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/20/2024
Plan of Correction
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Licensee agrees to submit a completed incident report to LPA Moleski by POC due date.
vincent.moleski@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 08/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2024
LIC809 (FAS) - (06/04)
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