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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802288
Report Date: 11/17/2022
Date Signed: 11/17/2022 01:17:51 PM


Document Has Been Signed on 11/17/2022 01:17 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
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: 6DATE:
11/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:33 AM
MET WITH:Carola White, Administrator, and StaffTIME COMPLETED:
12:37 PM
NARRATIVE
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On 11/17/22 at 10:33 am, Licensing Program Analyst (LPA) Chavez conducted an unannounced on-site annual infection control visit to the facility above. LPA met with Staff #1 (S1) on-site and Carola White, Administrator, by phone and explained the purpose of the visit.

LPA toured the facility with S1 and observed the following: The facility has infection control signage throughout the facility on handwashing, cough etiquette and use of masks. Staff are wearing masks. The facility does not have soap and paper towels in resident bathrooms (3). S1 states that staff assist dementia residents with toileting and pull these items from the locked cabinet in the bathrooms which LPA observed. Fire extinguishers (3) are located in the kitchen and bedroom hallways. The extinguishers are fully charged and were inspected on 1/12/22. The facility has a pool with two gates, one with a proper lock, the other with a rope lock. LPA pulled on the gate with the rope lock, and the gate opened about 1.5 feet which could possibly allow a small person into the pool area. Licensee will replace the lock to ensure the gate does not open and the pool is inaccessible to residents in care, take a video, and send to LPA by 11/18/22. The facility has an outdoor lamp on the wall of the building which is hanging by its wires. Licensee will secure the lamp, repair, or replace, and send a photo to LPA by 11/24/22. At 10:47 am, LPA observed cleaning supplies in one of the resident bathrooms accessible to residents. At 10:55 am, LPA observed the door from the kitchen to the pantry unlocked. LPA observed six containers of cleaning supplies and tools in the pantry accessible to residents. At 11:20 am, LPA observed a bottle of cleaning chemicals in the backyard. Deficiency cited on a 9099-D page.

At 11:51 am, LPA conducted the Infection Control mitigation module by phone with the administrator.

Exit interview conducted, deficiency cited and the report and appeal rights emailed to the licensee.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2022
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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Document Has Been Signed on 11/17/2022 01:17 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: PARADISE VALLEY CARE
FACILITY NUMBER: 405802288

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
87705 Care of Persons with Dementia. (f) The following shall be stored inaccessible to residents with dementia: (2)... toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement was not met based on LPA observations.
Deficient Practice Statement
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LPA observed three containers of cleaning supplies in an unlocked resident bathroom, six quart-size containers of dish soap and all-purpose cleaner in the unlocked kitchen pantry, and a quart-size container of industrial cleaner in the backyard accessible to residents.
POC Due Date: 11/18/2022
Plan of Correction
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Staff immediately locked the kitchen pantry and removed the chemicals in the bathroom and the backyard. Licensee will conduct staff training on ensuring that dangerous items are inaccessible to all residents in care. Licensee will ensure chemicals are in a permanent locked area inaccessible to residents. Licensee will provide proof to LPA by 11/18/22 that staff training is scheduled to be completed by 11/21/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2022
LIC809 (FAS) - (06/04)
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