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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802288
Report Date: 06/26/2023
Date Signed: 06/26/2023 12:12:30 PM


Document Has Been Signed on 06/26/2023 12:12 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: 5DATE:
06/26/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:StaffTIME COMPLETED:
12:25 PM
NARRATIVE
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On 6/26/23 at 11:15 AM, Licensing Program Analyst (LPA) De Leon conducted an unannounced Case Management visit in regards to the closure of this facility. LPA met with Care Staff and explained the purpose for the visit.

The licensee issued a 2 week notice to close the facility and did not provide residents or their responsible parties with a proper 60-day notice.

LPA toured the facility and observed adequate food of 2 day perishables and 7 day non-perishables and supplies, and confirmed that the utilities were functional.

Staff did not know which residents had placement and which did not. R1's family had contacted staff earlier this day and stated that R1 had placement and would be relocated later this week.

Exit interview conducted, deficiency cited on 809-D, report given, appeal rights given.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:
DATE: 06/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 06/26/2023 12:12 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: 06/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/27/2023
Section Cited
HSC
1569.682(a)(2)

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§1569.682(a)(2) Transfer of resident upon forfeiture of license.
Provide each resident or the resident’s responsible person with a written notice no later than 60 days before the intended eviction. This requirement was not met as evidenced by:
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Licensee agreed to issue a written statement of understanding of 1569.682 and confirming that if residents cannot be placed by June 30, the residents cannot be abandoned or put out on the street, and the licensee must ensure they receive safe placement. Provide (5) each residents relocation information to CCL.
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Based on record review and interview, the licensee did not comply with the above cited section when they failed to give 60 day notice of closure to residents, which posed an immediate health and safety risk for residents in care.
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The licensee stated there are financial issues and could not reach a deal for a change of ownership, prompting the need to close quickly.

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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: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:
DATE: 06/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2023
LIC809 (FAS) - (06/04)
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