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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700952
Report Date: 03/01/2023
Date Signed: 03/01/2023 11:14:45 AM


Document Has Been Signed on 03/01/2023 11:14 AM - 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: 0DATE:
03/01/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Angelita DayoanTIME COMPLETED:
11:20 AM
NARRATIVE
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Licensing Program Analyst (LPA) Christina Valerio contacted Licensee Angelita Dayoan regarding their closure of Padua Assisted Living 3.

On 01/23/23, LPA Valerio was verbally informed that Licensee Angelita Dayoan wanted to close Padua Assisted Living 3. Licensee stated there were no residents in care and they were moving out of the house by 01/25/23. LPA requested licensee send a letter of intent along with information regarding the residents. LPA sent a follow up email on 01/31/23 requested the letter of intent, to review PIN 21-05, and to fill out the closure roster excel spreadsheet. On 02/01/23, LPA received Angelita's letter informing the department that she decided to close Padua Assisted Living 3 as of 01/23/23. On 02/06/23, LPA received the closure roster of the 1 resident the facility had in care. According to Angelita, Licensee did not provide letters to residents of closure because she had no residents in care. On 02/10/23, LPA Valerio conducted a CM visit and observed no residents in care. Licensee stated she did not have access to the facility. LPA requested the original license. Licensee stated they packed it up during the move and can longer located the license. On 02/24/23, LPM Richardson requested a copy of the letters sent to families/responsible parties regarding the closure to the Regional Office by 02/27/23. According to records review, licensee moved the resident to another licensed facility owned by licensee.

As of 03/01/23, the Regional Office did not received copies of the letter sent to families/responsible parties. LPA requested this be sent to the RO by 03/02/23. LPA requested a copy of all resident admissions in 2022 along with their discharge dates/placement be sent to LPA by 03/02/23.

Per California Code of Regulations, Title 22, deficiencies are being cited today on LIC 809-D. Failure to correct deficiencies may result in civil penalties. Appeal rights provided. An exit interview was held with licensee, a copy of the report provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2023
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 03/01/2023 11:14 AM - 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: 03/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/03/2023
Section Cited

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87224 Eviction Procedures (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5). This requirement was not met as evidenced by:
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Licensee stated they will review the eviction procedures 87224 and send requested documentation to LPA by POC due date.
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Based on interviews, records review, and observation, the licensee did not ensure 1 out of 1 residents and responsible parties were provided an eviction notice. This poses a potential health and safety risk to residents in care
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Type B
03/03/2023
Section Cited

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1569.682 Transfer of resident ... duties of licensee; closure plan;...(a) A licensee of a licensed residential care facility for the elderly shall, prior to transferring a resident of the facility to another facility, as described in subdivision (a), (b), or (f) of Section 1569.19,shall, at a minimum, do all of the following:... This requirement was not met as evidenced by:
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Licensee stated they will review the health and safety code 1569.682 to ensure this occurence does npot happen again. Licensee to send requested documentation to LPA by POC due date.
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Based on observations, records review, and interviews, the licensee did comply with the health and safety code or Title 22 regulations, which poses a potential 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: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2023
LIC809 (FAS) - (06/04)
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