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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360909246
Report Date: 07/29/2024
Date Signed: 07/29/2024 06:00:53 PM

Document Has Been Signed on 07/29/2024 06:00 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:PADUA VILLAGE, INC.FACILITY NUMBER:
360909246
ADMINISTRATOR/
DIRECTOR:		SHAWN F. BARRACKSFACILITY TYPE:
735
ADDRESS:11981 MIDWAY RD.TELEPHONE:
(760) 248-6245
CITY:LUCERNE VALLEYSTATE: CAZIP CODE:
92356
CAPACITY: 26CENSUS: 19DATE:
07/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:35 PM
MET WITH:Denise Parra - Program DirectorTIME VISIT/
INSPECTION COMPLETED:
06:05 PM
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Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced required 1-year visit to the facility. LPA met with Denise Parra - Program Director and discussed the purpose of the visit.

The facility is Adult Residential Facility (ARF) with a current census of (19) clients. LPA conducted an overall inspection of the facility, which included, but was not limited to, the following:

Operation/Physical Plant:The facility’s indoor and outdoor passageways were kept free of obstruction. The facility’s has sufficient indoor and outdoor activity space for clients in care. The facility is equipped with laundry equipment, carbon monoxide alarms and telephone service. The facility has a sufficient supply of bed linen, towels, and hygiene products for clients in care. Client bedrooms were equipped with beds, bed linen, chairs, storage space and sufficient lighting. Client bathroom equipment was in operating condition. The hot water in client bathrooms tested at 111 degrees F.

Food Service:The kitchen and dining areas are maintained clean. The facility has sufficient non-perishable and perishable food for number of clients in care. The has sufficient cups, plates, and utensils for client use. Sharps, disinfectants and cleaning solutions are kept locked and store away from food areas.

Health Related Services:All client medications were labeled and centrally stored in a locked medication room. The facility has a first aid kit and manual.

Personnel/Client Records:Staff records audited had health screenings, criminal record clearances, first aid/CPR training certifications, and training. Client record review reveals, client #1 and client# 2 did not have a current individual personal plan file. Review of facility's emergency and disaster plan reveals to be incomplete.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
Document Has Been Signed on 07/29/2024 06:00 PM - It Cannot Be Edited


Created By: Magda Malcore On 07/29/2024 at 05:18 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PADUA VILLAGE, INC.
FACILITY NUMBER: 360909246

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80068.3(a)
Modifications to Needs and Services Plan
(a) The licensee shall ensure that each client's written Needs and Services Plan is updated as often as necessary to assure its accuracy, but at least annually. These modifications shall be maintained in the client's file.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by client #1 and client #2 did not have a current Individual personal plan on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/12/2024
Plan of Correction
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The Program Director/Licensee shall submit to the Licensing Agency documentation of client #1 and client #2's current needs and service plan by POC due date
Section Cited
Other Provisions
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2024


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 07/29/2024 06:00 PM - It Cannot Be Edited


Created By: Magda Malcore On 07/29/2024 at 05:18 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PADUA VILLAGE, INC.
FACILITY NUMBER: 360909246

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Other Provisions
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Type B
Section Cited
HSC
1565(a)(7)(H)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (7) Procedures that address, but are not limited to the following: (H) Procedures for confirming the location of each individual served by the facility during an emergency response.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not maintaining a complete written emergency and disaster plan on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/12/2024
Plan of Correction
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The Program Director/Licensee shall submit to the Licensing Agency a complete written emergency and disaster plan by POC due date.
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:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2024


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: PADUA VILLAGE, INC.
FACILITY NUMBER: 360909246
VISIT DATE: 07/29/2024
NARRATIVE
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Based on LPA observations and records reviewed, technical advisories and deficiencies were cited per Title 22 of the California Code of Regulations and Health and Safety Codes.

An exit interview was conducted where reports (LIC809 & LIC809-D) were discussed and copies were provided with appeal rights to the Program Director at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024
LIC809 (FAS) - (06/04)
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