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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360909246
Report Date: 09/19/2022
Date Signed: 09/19/2022 12:24:10 PM

Document Has Been Signed on 09/19/2022 12:24 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:PADUA VILLAGE, INC.FACILITY NUMBER:
360909246
ADMINISTRATOR:KIMBERLY ROWEFACILITY TYPE:
735
ADDRESS:11981 MIDWAY RD.TELEPHONE:
(760) 248-6245
CITY:LUCERNE VALLEYSTATE: CAZIP CODE:
92356
CAPACITY: 26CENSUS: 25DATE:
09/19/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Shawn Barracks, Program Director.TIME COMPLETED:
12:35 PM
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At 10:30 AM on 09/19/2022, Licensing Program Analyst (LPA) Rohit Lama made an unannounced Case Management Visit at Padua Village Inc to conduct a Health and safety Check related to complaint #56-AS-20220916133953. LPA was greeted and granted entrance by Shawn Barracks, Program Director.

During the visit, LPA conducted an inspection of facility premises and observed and spoke with residents in care. LPA noted 25 people in care. LPA spoke with a portion of the residents. All residents spoken to stated they were doing well, felt safe and cared for, and had no concerns at this time with the care being provided at the facility.

Food supply and resident medications were inspected and noted to be in adequate quantity.

At this time, no deficiencies were issued. No immediate health or safety concerns noted.

An exit interview was conducted, where this report was discussed with Shawn Barracks, Program Director, and a copy was also provided.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Rohit Lama
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2022
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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