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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700952
Report Date: 08/23/2021
Date Signed: 08/23/2021 04:08:55 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 LIVING 3FACILITY NUMBER:
342700952
ADMINISTRATOR:PADUA, NICHOLASFACILITY TYPE:
740
ADDRESS:9653 GLACIER CREEK WAYTELEPHONE:
(916) 218-8556
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 0DATE:
08/23/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Angelita Dayoan and Nicholas PaduaTIME COMPLETED:
03:42 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived at the facility to meet with Administrator Angelita and Administrator Nicholas. LPA Valerio was screened for COVID-19 symptoms with temperature taken prior to being allowed in the facility.

LPA Valerio observed 0 residents in care. LPA observed the home to be in compliance with Title 22 regulations. Administrators stated once the accept their first resident, they will e-mail LPA Valerio.
LPA Valerio and Administrator Angelita went over COVID-19 mitigation plan protocols, PIN 20-37, Guardian concerns, and discussed questions regarding Administrator's other licensed facilities. LPA Valerio gave business card with contact information.

LPA Valerio requested Administrator send an updated LIC 308 to show her designated administrator in her or Administrator Nicholas absence.

Exit interview held and a copy of the report was given to Administrator Angelita and Administrator Nicholas.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2021
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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