374603680-4-12-2023-08-AS-ARAZ-CQTP9P-20230412110725

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603680
Report Date: 04/12/2023
Date Signed: 04/12/2023 11:07:50 AM

Document Has Been Signed on 04/12/2023 11:07 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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	PARADISE HILLS RESIDENTIAL CARE #2		FACILITY NUMBER:	374603680
ADMINISTRATOR:	CHUA, NENITA		FACILITY TYPE:	735
ADDRESS:	6950 DYLAN STREET		TELEPHONE:	(619) 434-1570
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92139
CAPACITY: 4		CENSUS: 4	DATE:	04/12/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Licensee Nenita Chua and Administrator Robert Chua		TIME COMPLETED:	11:40 AM

NARRATIVE

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Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit licensee Nenita Chua and Administrator Robert Chua .

According to the facility’s license, the facility has a maximum capacity of four (4) clients, of which all must be ambulatory During today’s inspection, there were a total of four (4) clients in care. This facility does not feature a secured perimeter or delayed egress doors. Required licensing postings were observed in visible areas of the facility.

LPA, accompanied by licensee’s staff, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens, hygiene supplies, and Personal Protective Equipment (PPE) were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities.

LPAs observed via measurement with a thermometer device that hot water temperature at taps accessible to clients were compliant. Kitchen was 105 F, Bathroom #1 was 110 F, and Bathroom #2 was 111 F and bathroom #3 was 105 F.

[CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023

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 04/12/2023 11:07 AM - It Cannot Be Edited

Created By: Alyssa Ramirez On 04/12/2023 at 10:48 AM

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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: PARADISE HILLS RESIDENTIAL CARE #2	FACILITY NUMBER: 374603680
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80066(a)(10)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in 1 out of 4 staff(S1) which posed a potential health risk to persons in care.
	POC Due Date: 04/22/2023
	Plan of Correction
1 2 3 4	Licensee agreed to arrange S1 to get LIC503 health screening report filled out and signed by a medical provider and place signed form in employee file. Licensee agrees to email a copy of S1 signed LIC 503 by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4	Licensee agreed to E-mail LPA copies of S1 LIC503 by the POC due date.
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Simon Jacob

LICENSING EVALUATOR NAME:

Alyssa Ramirez

LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023

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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: PARADISE HILLS RESIDENTIAL CARE #2	FACILITY NUMBER: 374603680
	VISIT DATE: 04/12/2023

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[CONTINUED FROM LIC 809]

There was no pool or large bodies of water on the premises. According to the licensee, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA interviewed multiple staff and clients, and LPA reviewed multiple staff and client records/files. The interviews did not raise any licensing concerns. Staff #1 (S1) did not have required form LIC503 Health Screening. Aside from the missing form, client and staff files contained the required documents. Confidential records were stored in locked areas.

Deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). Plans of Correction were jointly developed with the licensee. An exit interview was conducted with Licensee Nenita Chua and Administrator Robert Chua, to whom a copy of this report, the LIC 809-D and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023

LIC809 (FAS) - (06/04)

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