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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700843
Report Date: 02/25/2022
Date Signed: 02/25/2022 01:19:30 PM


Document Has Been Signed on 02/25/2022 01:19 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 LIVING 2FACILITY NUMBER:
342700843
ADMINISTRATOR:DAYOAN, ANGELITAFACILITY TYPE:
740
ADDRESS:2929 BABSON DRIVETELEPHONE:
(916) 478-2915
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:6CENSUS: 5DATE:
02/25/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:37 PM
MET WITH:Facility StaffTIME COMPLETED:
01:20 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) Christina Valerio arrived to the facility unannounced to conduct a case management visit. LPA's temperature was taken prior to being allowed entry into the facility. LPA confirmed with staff that zero residents or staff have displayed signs or symptoms of COVID-19 in the last 10 days. LPA explained the purpose of the visit and met with staff on shift.

LPA Valerio interview 1 staff. Staff stated the licensee is Angelita Dayoan and the Administrator is Karl Padua. No notices of change of ownership has been given to staff or residents. Administrator Certificate #6057871740 Expiration Date: 11/16/2022. According to facility records, Karl was designated as the acting administrator on 08/20/2021.

LPA interacted with Resident 1 (R1) during today's visit. R1 stated R1 has lived at the facility for one year and enjoys living here. R1 was observed watching television, eating R1's favorite crackers, and interacting with the staff. Residents 2 - 5 were in their room taking a nap.

LPA observed the following documents posted in the common area for public review: LIC 500 Personnel Roster, LIC 309 Administrative Organization, COVID -19 Informational, LIC 308 Designated Responsibility of Facility, most recent licensing report, personal rights, most recent PIN from CCLD, and Emergency Plan

Based on observations and interviews, no deficiencies were observed. Exit interview held with facility staff and a copy of the report was left at the facility.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2022
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 1