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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802288
Report Date: 01/26/2022
Date Signed: 01/26/2022 05:34:38 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:PARADISE VALLEY CAREFACILITY NUMBER:
405802288
ADMINISTRATOR:CAROLA WHITEFACILITY TYPE:
740
ADDRESS:9525 GALLINA CTTELEPHONE:
(805) 468-4141
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY:15CENSUS: 8DATE:
01/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Kenneth Freel, Licensee/Owner, Carola White, Med-techTIME COMPLETED:
03:28 PM
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At 1:45 pm, on 1/26/2022, Licensing Program Analyst (LPA) Darlene Chavez conducted an unannounced annual infection control inspection of the facility above. LPA met with Kenneth Freel, Licensee/Owner, and Carola White, med-tech, and informed staff of the reason for the visit. LPA, licensee, and Ms. White toured the facility.

LPA’s initial tour of the facility resulted in observations which were immediately corrected. LPA was screened upon entry to the facility by staff. At 2:07 pm, LPA observed that each resident bathroom does not have hand soap. Ms. White stated that soap is stored in a locked cabinet in the hall bathroom and that staff grab soap from the hall bath to wash residents’ hands. LPA instructed licensee to have hand soap available in each bathroom in a locked drawer or cabinet. Kitchen water temperature was at 117.3 F, bathroom #1 at 118.5 F, bathroom #2 at 118 F, and bathroom #3 at 105.3 F. Licensee will provide all CDSS PINs or PIN summaries for review by staff and residents. Licensee has agreed to ensure all staff are fit tested for N95 respirators. At 2:30 pm, LPA observed that the facility has an 11”x14” CCLD reporting poster. Administrator will print and post a 20”x26” color poster in facility in a common area.

At 2:45 pm, LPA conducted the Infection Control mitigation module with the licensee and Ms. White. No deficiencies noted.

Exit interview conducted and report emailed to the licensee.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2022
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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