374601395-1-2-2024-08-AS-AROS-CZ4NB9-20240102091846

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374601395
Report Date: 12/29/2023
Date Signed: 01/02/2024 09:19:12 AM

Document Has Been Signed on 01/02/2024 09:19 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	PARADISE VALLEY MANOR		FACILITY NUMBER:	374601395
ADMINISTRATOR:	AARON BURRUP		FACILITY TYPE:	741
ADDRESS:	2575 E. EIGHTH STREET		TELEPHONE:	(619) 470-6700
CITY:	NATIONAL CITY	STATE: CA	ZIP CODE:	91950
CAPACITY:	50	CENSUS:	DATE:	12/29/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	04:00 PM
MET WITH:	Wellness Director Cecy Salomon		TIME COMPLETED:	05:30 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced Case Management - Incident visit. LPA was welcomed by and identified himself to Wellness Director Cecy Salomon. LPA then met and discussed the purpose of the visit with Wellness Director Cecy Salomon.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 12/28/2023). According to the LIC624: on 12/26/2023, Client #1 (C1) went AWOL (absent without leave) from the facility. [See LIC 811 Confidential Names List for a description of C1.]

As of today’s (12/29/2023) licensing visit, C1 has not yet returned to Paradise Valley Manor. LPA also reviewed pertinent records and interviewed relevant staff.

According to C1’s latest LIC602 Physician’s Report (dated 4/24/2023): C1’s primary diagnoses were HTN, CHF and DM and difficulty walking. No Psychiatric issues are noted. Doctor determined that C1 is not able to safely leave the facility unassisted because is wheelchair dependent. Records and interviews revealed: C1 had lived at the facility for around two (2) years, and this was C1’s first AWOL incident since moving in. He is own responsible party.

According to the facility’s Absentee Notification Plan/Policy: When a client such as C1 is AWOL from the facility, staff are to search the “surrounding area.” After the unsuccessful search, staff are to notify the administrator or the Wellness Director and then law enforcement. The procedure was followed.

[Continued 809-C]

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2023

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 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: PARADISE VALLEY MANOR	FACILITY NUMBER: 374601395
	VISIT DATE: 12/29/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

[Continued form 809]

Facility staff conducted a search of the surrounding neighborhood(s) via automobile and walking. After one and half (1 ½) hours of unsuccessful searching, the Wellness Director filed a missing person’s report with law enforcement. The National City police department called Wellness Director Salomon and asked for descriptive information. A helicopter was dispatched. Around 1:00 am the police department called to report they were unable to locate C1.

CCLD concluded: Facility staff provided needed supervision to C1 leading up to the AWOL. Licensee had a written Absentee Notification Plan as part of C1’s record of care, and staff followed this plan.

No deficiencies were cited at this time for the above incident. No deficiencies were observed or cited during today's visit.

An exit interview was conducted with Wellness Director Salomon, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2