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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 04:15:39 PM

Document Has Been Signed on 10/15/2024 04:15 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:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Tiffany StevensonTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Unannounced Case Management 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.
The purpose of this case management visit was to follow up on an incident that recently took place involving facility residents.
A brief discussion was held with the facility designated Administrator, Ada Osuka, over the telephone.
A brief discussion was held with the facility house manager, Tiffany Stevenson, at this time.
It was learned that all responsible parties for the facility residents were notified about the incident. Third party vendors were also notified to address any changes and supplements to the facility residents as well.

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

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
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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