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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200921
Report Date: 05/03/2023
Date Signed: 05/03/2023 11:05:39 AM

Document Has Been Signed on 05/03/2023 11:05 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:PARADISE MANOR 3FACILITY NUMBER:
435200921
ADMINISTRATOR:MIGUEL, LYNDAFACILITY TYPE:
735
ADDRESS:19147 MURIEL LANETELEPHONE:
(408) 257-2953
CITY:CUPERTINOSTATE: CAZIP CODE:
95014
CAPACITY: 6CENSUS: 5DATE:
05/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Licensee Lynda MiguelTIME COMPLETED:
11:10 AM
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Licensing Program Analysts (LPAs) Simi Rai and Manuel Monter conducted an unannounced Required 1 Year visit and met with Licensee Lynda Miguel and David Miguel.

During visit, LPAs toured the inside and outside of the facility. LPAs toured the facility kitchen and observed food supply of at least 2 days of perishable food supply and at least 7 days of nonperishable food supply. Sharps and medications were locked in secured areas. There was a first aid kit in the facility. LPAs observed additional food supply areas and secured areas for cleaning supplies and laundry detergents.

The facility bathroom had available soap, paper towels, and trash cans with lids. The shower had grab bars, non-skid mats and and a shower chair. The water temperature in the bathroom sinks ranged from 116.6F-115.5F. The water temperature in the kitchen sink was 116.1F. Fire extinguisher was observed and inspected on May 2022.

Facility smoke detectors were tested and found to be functioning when tested. Four out of Four resident bedrooms had available bedding, drawers, and functioning lights.

When touring the outside area of the facility, the exits were cleared of obstruction.

LPAs reviewed facility records for staff and residents. LPAs reviewed resident medications and central stored medication records. LPAs conducted interviews with 4 staff (S1-S4). 5 out 5 residents were attending day program during visit.

This report was reviewed with Licensee David Miguel and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2023
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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