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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005829
Report Date: 03/05/2025
Date Signed: 03/05/2025 03:54:48 PM

Document Has Been Signed on 03/05/2025 03:54 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:PARADISE RESIDENTIAL CAREFACILITY NUMBER:
397005829
ADMINISTRATOR/
DIRECTOR:		ADA P. OSUKAFACILITY TYPE:
735
ADDRESS:2673 EAST JUNCTION DRIVETELEPHONE:
(209) 910-0900
CITY:MANTECASTATE: CAZIP CODE:
95336
CAPACITY: 6CENSUS: 4DATE:
03/05/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:03 PM
MET WITH:Ada OsukaTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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On 3/5/2025 at 2:00pm, Licensing Program Analysts (LPAs) Michael Bilger and Noel Wolf Petersen arrived unannounced to conduct a case management visit related to complaint #27-AS-20241223102104. LPA met with Administrator Ada Osuka and explained the purpose of the visit. LPA conducted interview with three staff members and one resident in care. LPA also reviewed facility file documentation including staff schedule, individual program plans (IPPs) for resident1 (R1) and R2, incident reports, needs and services plans, and physician’s reports. LPA also conducted a facility observation on 3-5-25 and reviewed a police report associated with the above complaint number.

Based on interviews and record reviews, it was revealed that on 12-18-2024 at approximately 11:45pm, a staff member was doing rounds. When staff member entered room of R2, staff observed R1 running into the bathroom belonging to R2. Staff member then redirected R1 and informed R1 he was not to go into other bedrooms. Based on interview and record review, staff member questioned R2 as to the nature of R1’s presence at which time R2 revealed he was touched inappropriately by R1. A review of R1’s IPP dated 7/22/2024 revealed R1 is to be in “line of sight” supervision at all times due to a previous documented history of behaviors.

As a result, there is a preponderance of evidence to conclude staff did not provide line of sight supervision at all times as required and stated in R1's IPP. As a result of today’s case management, citation is issued under Title 22, Division 6 and noted on LIC 809D. An exit interview was conducted with Administrator and a copy of this report was provided. Appeal rights provided.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2025
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 03/05/2025 03:54 PM - It Cannot Be Edited


Created By: Michael Bilger On 03/05/2025 at 03:17 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PARADISE RESIDENTIAL CARE
FACILITY NUMBER: 397005829

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/14/2025
Section Cited
CCR
85078(a)(1)

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85078(a)(1) Responsibility for Providing Care and Supervision. (a)In addition to Section 80078, the following shall apply: (1) The licensee shall provide those services identified in the client's needs and services plan as necessary to meet the client's needs. This requirement was not met as evidenced by:
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Licensee will ensure completed staff training on appropriate care and supervision techniques for residents in care. Licensee to audit IPPs and other documentation, and ensure training includes specifics to each resident’s required supervision level. Proof of completed training to be submitted to LPA by POC due date.
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 Based on interview and record review, staff did not provide the appropriate level of supervision for R1 identified in R1’s IPP. This posed a potential health and safety risk for resident 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:Liza King
LICENSING EVALUATOR NAME:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2025


LIC809 (FAS) - (06/04)
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