397005829-10-31-2023-27-AS-CYAG-CX5TAH-20231031143334

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 397005829
Report Date: 10/25/2023
Date Signed: 10/31/2023 02:33:39 PM

Document Has Been Signed on 10/31/2023 02:33 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	PARADISE RESIDENTIAL CARE		FACILITY NUMBER:	397005829
ADMINISTRATOR:	ADA P. OSUKA		FACILITY TYPE:	735
ADDRESS:	2673 EAST JUNCTION DRIVE		TELEPHONE:	(209) 910-0900
CITY:	MANTECA	STATE: CA	ZIP CODE:	95336
CAPACITY: 6		CENSUS: 5	DATE:	10/25/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Theresa Katz		TIME COMPLETED:	04:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Unannounced annual visit made out to this facility on 10/25/2023 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility caregiver, Theresa Katz, who was briefly interviewed. This LPA requested that she go ahead and contact the facility designated Administrator to let her know that CCL was present at this time for an annual visit. It was learned that the facility designated Administrator Ada Osuka was unavailable at this time and would not be able to be present for today's annual visit. Current census was 5 residents and they were all present at the time of this visit. This facility was vendorized through Valley Mountain Regional Center to accept and retain Level 4I residents at any given time. Tour of this facility was conducted. Kitchen area was toured. Cabinets and drawers were reviewed. Medication cabinet was observed to be present and properly locked to make it inaccessible to the residents at all times. Policies and procedures were discussed with the facility caregiver in terms of dispensing, documenting, and overall administration of resident medications. First aid kits were observed to be present and contained all of the necessary components at this time. Policies and procedures were discussed in relation to the documentation of the medications that required initials by incoming staff and outgoing staff. A review was conducted in regards to this documentation of the resident medication administration record and dispensing log. A tour of the facility resident rooms was conducted. Resident furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. Resident restrooms were toured and observed to be able to meet the needs of the residents at this time. Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees at this time. Living area, dining area, and all other areas intended for resident use were toured and observed to be in compliance at this time. Fire extinguishers (2), located in the kitchen area and facility hallway, were observed to have been

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PARADISE RESIDENTIAL CARE	FACILITY NUMBER: 397005829
	VISIT DATE: 10/25/2023

NARRATIVE

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annually inspected by the local fire extinguisher company, Jorgensen Fire, on 06/27/2023 and in compliance at this time.
Laundry area, located in the garage area, was toured. Chemicals, detergents, and bleaches were observed to be locked and made inaccessible to the residents at this time.
Garage area was toured. Additional food storage unit was observed to be present and functional at this time.
A review of the food supply was conducted to make sure that there was a sufficient amount of 2-day perishable and 7-day nonperishable quantities at all times.

Exterior grounds of this facility were toured. A review of the facility perimeter fence, side gate, and exits was conducted.

A review of the facility staff and resident files could not be completed for today's annual visit since the facility staff did not have access to them. These folders were stored and maintained in the facility office which only the facility designated Administrator had access.

This LPA will have to return at a later date to conduct a review of the facility staff and resident records in order to complete this annual visit.

Exit Interview

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

LIC809 (FAS) - (06/04)

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