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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005829
Report Date: 10/14/2024
Date Signed: 10/15/2024 04:16:08 PM

Document Has Been Signed on 10/15/2024 04:16 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: 5DATE:
10/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Tiffany StevensonTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Unannounced Annual Licensing visit made out to this facility on 10/14/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility house manager, Tiffany Stevenson, at this time. A brief interview was conducted with the facility house manager at this time.
This LPA requested that she go ahead and contact the facility designated Administrator, Ada Osuka, to inform her that CCL was present at this time.
It was learned that this facility was vendorized to be able to accept and retain up to (6) Level 4I residents at any given time.
This facility is licensed to serve up to (5) Ambulatory only residents and (1) Non Ambulatory resident at any given time. Current census was 5 residents, of which (5) of them, were out of the facility at their respectable day programs at this time.
Tour of this facility was conducted.
A tour of the facility kitchen area was conducted. Drawers and cabinets were opened and the items enclosed were reviewed at this time. Drawers housing knives and sharps were observed to be locked and made inaccessible to the residents at this time.
Cleaning agents, bleach, and other supplies which were stored in a closet were observed to be locked and made inaccessible to the residents at this time.
A review of the facility food supply was conducted. A review of the facility's 2-day perishable foods and 7-day nonperishable foods was conducted to make sure that there were sufficient quantities on hand at all times.
Medication cabinet, located in the facility staff room, was reviewed. Policies and procedures involving handling, dispensing, and documentation of the resident medications were discussed with the facility designated staff member at this time. A review of the facility Medication Administration Record and dispensing log was conducted.
Medication cabinet was observed to be locked and made inaccessible to the residents at this time.
Living room, dining area, and all other areas intended for resident use were observed to furnished and
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2024
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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: PARADISE RESIDENTIAL CARE
FACILITY NUMBER: 397005829
VISIT DATE: 10/14/2024
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maintained in compliance at this time and able to meet the needs of the residents.
A tour of the resident bedrooms was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
A tour of the resident restrooms was conducted.
Hot water temperatures were taken to make sure that they measured within the allowed range of 105-120 degrees at all times.
Laundry area, located next to the garage area, was toured. Cleaning supplies, detergents, and bleach were observed to be locked and made inaccessible to the residents at this time.
Linen closet was reviewed. Bed sheets, linens, and towels were observed to be sufficient and able to meet the needs of the residents at this time.
A tour of the garage area was conducted.
First aid kits were observed to be present and contained all of the required components at this time.
Fire extinguishers were observed to be placed near the kitchen area of this facility and were recently reviewed on 06/28/2023 by the local fire extinguisher company, Nor-Cal Fire Inc., at this time.
A tour of the exterior grounds for this facility was conducted. A review of the facility perimeter fence, side gates, and exits was conducted.
This LPA was unable to review any of the facility staff files since they were locked in the facility office cabinets and the current staff persons did not have access to them at this time.
This LPA was unable to review any of the facility resident files since they were locked in the facility office cabinets and the current staff persons did not have access to them at this time.

This LPA was unable to conclude this annual visit since the document review section was unable to be completed today. Another attempt will be made to complete this annual visit by reviewing all of the resident and staff files at a later date and time.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2024
LIC809 (FAS) - (06/04)
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