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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603680
Report Date: 05/22/2023
Date Signed: 05/22/2023 03:53:44 PM

Document Has Been Signed on 05/22/2023 03:53 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:PARADISE HILLS RESIDENTIAL CARE #2FACILITY NUMBER:
374603680
ADMINISTRATOR:CHUA, NENITAFACILITY TYPE:
735
ADDRESS:6950 DYLAN STREETTELEPHONE:
(619) 434-1570
CITY:SAN DIEGOSTATE: CAZIP CODE:
92139
CAPACITY: 4CENSUS: 4DATE:
05/22/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Nenita Chua, LicenseeTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dawn Segura conducted a case management visit to cite for a deficiency observed during a complaint investigation. LPA met with Nenita Chua, Licensee, with whom she discussed the purpose of the visit.

During a complaint investigation, LPA discovered, through a review of record and interview that a medication administration record (MAR) maintained by the facility is not accurate. MAR maintained for Client 1 (C1) [LIC 811 Confidential Names List was provided to identify the client] reflects that a medication was administered; however, it was determined that the medication was still in the bubble pack on date marked as medication administered.

Based upon the foregoing, a deficiency is being cited Per Title 22, Division 6, Chapter 8 of the California Code of Regulations and is listed on an LIC 809-D.

An exit interview was conducted, and this report was discussed with Nenita Chua, Licensee. Copies of this report and Licensee/Appeal Rights (LIC 9058) were provided to the licensee, and her signature on this form acknowledges receipt of the rights and a copy of this report.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dawn Segura
LICENSING EVALUATOR SIGNATURE: DATE: 05/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2023
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 05/22/2023 03:53 PM - It Cannot Be Edited


Created By: Dawn Segura On 05/22/2023 at 03:15 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
, 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: 05/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/05/2023
Section Cited
CCR
80070(a)

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Client Records. The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.

This requirement was not met, as evidenced by:
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Licensee provided proof of training that was completed on 5/19/2023 by staff who currently work in the facility.

The deficiency is cleared during today's visit.
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Based on records review and interview, licensee did not maintain a current medication administration record for C1 and C2, 1 of 4 clients in care. This posed a potential health risk for persons 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:Lizzette Tellez
LICENSING EVALUATOR NAME:Dawn Segura
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2023


LIC809 (FAS) - (06/04)
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