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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700952
Report Date: 11/17/2021
Date Signed: 11/17/2021 10:22:12 AM

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: 3DATE:
11/17/2021
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Angelita Dayoan, Nicholas PaduaTIME COMPLETED:
10:22 AM
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct a post-licensing visit. LPA Valerio introduced herself, met with Licensee Angelita Dayoan, and was screened prior to being allowed entry into the facility. Staff confirmed residents or staff have not had any signs of COVID-19 in the last 10 days.

LPA Valerio and Licensee/Administrator Nicholas and Angelita toured the facility inside and out to ensure compliance of Title 22 regulations. All emergency exits were clear from obstructions, resident rooms were clean and furnished, bathrooms were sanitary, and common areas were clean.

LPA Valerio reviewed 3 staff files. Staff files had required documentation and training. Resident files and centrally stored log were reviewed and completed with necessary documentation.

No health or safety concerns observed during the visit. No deficiencies were observed during the visit. Exit interview held and a copy of the report was given to Licensee Administrator Angelita and Nicholas.







SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021
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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