374604395-1-25-2024-08-AS-THOS-CZU2AK-20240125161339

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604395
Report Date: 01/25/2024
Date Signed: 01/25/2024 04:14:23 PM

Document Has Been Signed on 01/25/2024 04:14 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 DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	PARADISE TRINITY HOME #2		FACILITY NUMBER:	374604395
ADMINISTRATOR:	ALCANTARA, RAY NEIL		FACILITY TYPE:	735
ADDRESS:	9972 JAVELIN WAY		TELEPHONE:	(619) 278-1811
CITY:	SPRING VALLEY	STATE: CA	ZIP CODE:	91977
CAPACITY: 4		CENSUS: 2	DATE:	01/25/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:25 PM
MET WITH:	Rayda Alcantara, Administrator		TIME COMPLETED:	02:30 PM

NARRATIVE

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Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was greeted and allowed entry into the facility by Rayda Alcantara, Administrator, to whom LPA discussed the purpose of the visit. Administrator Rayneil Alcantara arrived during the visit.

According to the facility’s license, the facility has a maximum capacity of four (2) developmentally disabled adults, all ambulatory. During today’s inspection, two (2) clients were at day program.

LPA, accompanied by the Administrator, 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, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was comfortable.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas.

[CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024

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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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 TRINITY HOME #2	FACILITY NUMBER: 374604395
	VISIT DATE: 01/25/2024

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[CONTINUED FROM LIC 809]

No pools or bodies of water on the premises. Per Administrator Alcantara no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher has been serviced. First aid kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA interviewed staff present. There were no clients at the facility during the visit. LPA reviewed multiple staff and client records/files. Files reviewed contained required documents. Confidential records were stored in locked areas. Administrator presented proof of current/active business liability insurance and surety bond.

Deficiencies were observed and cited during today's annual inspection.

An exit interview was conducted with Rayda Alcantara, Administrator to whom copies of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit.

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/25/2024 04:14 PM - It Cannot Be Edited

Created By: Tiffany Holmes On 01/25/2024 at 01:58 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 TRINITY HOME #2	FACILITY NUMBER: 374604395
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85068.2(b)(1)(C)

Needs and Services Plan

(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (C) The written medical assessment specified in Section 80069. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in 1 out of 2 clients which poses a potential health, to persons in care.
	POC Due Date: 02/08/2024
	Plan of Correction
1 2 3 4	LPA requested medical assessment to be completed and submitted to CCL by POC date of 02/08/2024.

Type B

Section Cited

CCR

85068.2(b)(1)(F)

Needs and Services Plan

(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (F) The written functional capabilities assessment specified in Section 80069.2. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in 2 out of 2 clients which poses a potential safety risk to persons in care.
	POC Due Date: 02/02/2024
	Plan of Correction
1 2 3 4	LPA requested the needs and services plans to be completed and submitted to CCL by POC date of 02/02/2024.

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:

Denise Powell

LICENSING EVALUATOR NAME:

Tiffany Holmes

LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024

LIC809 (FAS) - (06/04)

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