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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700952
Report Date: 02/25/2022
Date Signed: 02/25/2022 03:21:04 PM


Document Has Been Signed on 02/25/2022 03:21 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 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:
02/25/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:52 PM
MET WITH:Angelita Dayoan TIME COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived at the facility unannounced to conduct a case management visit. LPA Valerio was screened for COVID-19 with temperature taken prior to being allowed entry into the facility. LPA explained the purpose of the visit and was met by Licensee Angelita Dayoan. Licensee confirmed zero residents or staff have displayed any signs or symptoms of COVID-19 in the last 10 days.

LPA Valerio toured the physical plant to ensure the health and safety of residents and to ensure the facility is in compliance of Title 22 regulations. LPA observed 3 residents present in the facility. Resident 1 was sleeping, Resident 2 was reading a book, and Resident 3 was walking in the backyard with staff. LPA interacted with 2 residents during the visit. Residents appeared to be content. Resident rooms had necessary furniture and were free from debris. Facility was clean and free from odors.

LPA Valerio observed active liability insurance and administrator certificate posted in the facility. LPA reviewed and obtained a copies of the Licensee's proof of Control of Property for all homes licensed under their names. Licensee stated they are not in the process of changing ownership or selling their business.

Based on observations and interview, no deficiencies were observed. Exit interview held and a copy of the report was given to Licensee Angelita Dayoan and Nicholas Padua.
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)
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