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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700952
Report Date: 04/12/2022
Date Signed: 04/12/2022 03:13:30 PM


Document Has Been Signed on 04/12/2022 03:13 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: 4DATE:
04/12/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Angelita DayoanTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst(LPA) Victoria Brown arrived unannounced on 4/12/22 at 2:30pm to conduct a Case Management visit. LPA was met by Angelita Dayoan and stated the purpose of the visit. LPA provided a copy of the staff roster during this visit. During a file review, Community Care Licensing LPA observed that the licensing fees are not current. The fees in the amount of $742.00 are due as of 3/11/22 which may include late fees. LPA provided a PIN as an option to pay the fees online. LPA conducted a health and safety check on residents receiving care and supervision.

LPA toured the facility to ensure there no areas that would pose a health, safety or personal rights risk to residents in care. Currently, there are 4 residents receiving care and supervision. The fire extinguishers, carbon and smoke detectors were present. LPA observed residents participating in individual activities. LPA observed 2-day perishables and 7-day non-perishables. The hot water measured at 111.4*F which is within the required range of 105-120*F. The temperature inside the facility measured at 72*F which is within the required range of 68-85*F.

LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA did not observe any health and safety concerns during this visit.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Administrator was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, and a copy of the report was given.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2022
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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Document Has Been Signed on 04/12/2022 03:13 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 3
FACILITY NUMBER: 342700952

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/13/2022
Section Cited

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Licensing Fees

The failure of an applicant for licensure or a licensee to pay all applicable and accrued fees and civil penalties shall constitute grounds for denial or forfeiture of a license.
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This requirement is not met as evidenced by: Administrator/License did not ensure fees were paid timely.
Based on a file review the fees are not current.
This possess an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2022
LIC809 (FAS) - (06/04)
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