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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700952
Report Date: 01/25/2022
Date Signed: 01/25/2022 04:11:14 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: 2DATE:
01/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:11 PM
MET WITH:Angelita DayoanTIME COMPLETED:
04:25 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived at this facility unannounced to conduct an annual inspection visit LPA Valerio was screened for COVID-19 symptoms with temperature prior to being allowed inside the facility. Administrator confirmed staff and residents have not displayed any signs or symptoms of COVID-19 in the last 10 days.
 
The physical plant was toured inside and outside to ensure the safety of the residents and compliance with Title 22 regulations. LPA conducted the infection control domain tool. LPA observed the facility to have COVID-19 informational and hand washing signs posted at the front door and throughout the facility. LPA Valerio and Administrator discussed recent PINs regarding boosters, vaccinations, and visitation procedures and mandates. LPA reviewed updated mitigation plan and emergency disaster plan with Licensee. The facility has a stock of PPE for a minimum of 30 days. Hand sanitizer was observed to be available in common areas. An emergency supply of food and first aid kit was observed.
 
The temperature inside the facility was measured at 72*F. The hot water was measured at 112.3*F. Facility has nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. LPA observed the centrally stored medications area and cleaning supplies to be locked and inaccessible to clients. Resident rooms was sanitary and had the required furniture and furnishings. Fire extinguishers was up to date with last check on 05/20/2021. LPA interacted with two residents and 1 staff during the visit.

LPA reviewed 2 resident, 2 staff files, and Centrally Stored Medication Logs. LPA requested updated documentation, which Administrator will send by COB 01/28/2022.
 
Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed during this visit. An exit interview was held, and a copy of the report was left with Licensee Angelita Dayoan.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2022
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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