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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005829
Report Date: 10/15/2021
Date Signed: 10/19/2021 11:02:10 AM

Document Has Been Signed on 10/19/2021 11:02 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:PARADISE RESIDENTIAL CAREFACILITY NUMBER:
397005829
ADMINISTRATOR:ADA P. OSUKAFACILITY TYPE:
735
ADDRESS:2673 EAST JUNCTION DRIVETELEPHONE:
(209) 910-0900
CITY:MANTECASTATE: CAZIP CODE:
95336
CAPACITY: 6CENSUS: 5DATE:
10/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Ada OsukaTIME COMPLETED:
12:30 PM
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Unannounced annual visit made out to this facility on 10/15/2021 by this LPA Charlie Yang who was met by the facility caregivers. A brief interview was conducted with the caregivers who were present at this time. This LPA requested that the caregivers go ahead and contact the facility designated Administrator, Ada Osuka, to inform her that CCL was present at this time. The facility designated Administrator arrived later on while this LPA was present.
Current census was 5 residents who were all present since their respectable day programs were unavailable due to COVID restricted activities at this time.
This facility is licensed to serve and accept up to 6 residents who are deemed to be ambulatory and (1) non ambulatory as well. This facility is vendorized to accept and retain Level 4I residents at any given time.
Tour of the facility was conducted.
Dining area, living areas, and all other areas intended for resident use were toured. It was observed that furniture and furnishings were sufficient and able to meet the needs of the residents at this time.
Kitchen area was toured. Cabinets and storage units for cook ware and kitchen ware were observed to be sufficient and able to meet the needs of the residents at this time.
Food storage units, facility refrigerator unit and freezer unit, were reviewed for adequate 2-day perishable and 7-day non perishable quantities at this time. Pantry area housing dry goods and products was toured. Medication cabinet was reviewed. Policies and procedures were discussed with the facility designated Administrator in regards to dispensing, documenting, and communication for all involved parties.
First aid kits were observed to be present and contained all of the required components at this time.
Fire extinguishers were observed to have been annually inspected on 05/21/2021 by the local fire equipment company and found to be in compliance at this time.
A tour of the resident bedrooms was conducted. Bedroom furniture and furnishings were observed to be sufficient and in compliance at this time.
It was observed that all of the resident bedrooms were private and none of them were shared at this time. A tour of the facility staff room was toured as well.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2021
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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: PARADISE RESIDENTIAL CARE
FACILITY NUMBER: 397005829
VISIT DATE: 10/15/2021
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Linen supplies were reviewed and observed to be in compliance at this time.
A tour of the exterior grounds was conducted. A review of the perimeter fence, side gates, and exterior exits was conducted.

This LPA requested the following forms and documents from this facility to be updated and submit into CCL:

LIC 308

LIC 400

LIC 500

LIC 610

There were no deficiencies observed or cited during today's annual visit.

Exit Interview
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021
LIC809 (FAS) - (06/04)
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