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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200921
Report Date: 05/22/2024
Date Signed: 05/22/2024 12:24:40 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 05/22/2024 12:24 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:PARADISE MANOR 3FACILITY NUMBER:
435200921
ADMINISTRATOR/
DIRECTOR:		MIGUEL, LYNDAFACILITY TYPE:
735
ADDRESS:19147 MURIEL LANETELEPHONE:
(408) 257-2953
CITY:CUPERTINOSTATE: CAZIP CODE:
95014
CAPACITY: 6CENSUS: 6DATE:
05/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Direct Support Staff, Melanie GavinalTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit and met with Direct Support Staff, Melanie Gavina. LPA Rai spoke with Licensee/Administrator, Lynda Miguel and stated the purpose of today's visit. LPA Rai observed 3 staff and 6 residents at the facility. During the visit, 5 residents were ready to attend day program and left the facility.

During visit, LPA Rai toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Sharps and medications were locked in secured areas. LPA observed additional food supply areas and secured areas for cleaning supplies and laundry detergents.

LPA Rai toured the resident bedrooms. 4 out of 4 resident bedrooms had available bedding, drawers, and functioning lights. LPA Rai toured the office and observed a bed. ADM states the bed is for lounging for staff and the office is not used as a bedroom for any person.

The facility bathroom had available soap, paper towels, and trash cans with lids. The water temperature in the bathroom sinks ranged from 110.1 degrees F - 110.3 degrees F. The water temperature in the kitchen sink was 114.2 degrees F.

Fire extinguisher was observed and inspected on 04/25/2024. Facility smoke detectors and carbon monoxide detectors were in working condition. The last disaster drill was conducted on 4/13/2024 and 4/14/2024.

LPA Rai reviewed facility records for 3 staff and 3 residents. LPA Rai reviewed resident medications and central stored medication records. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Direct Support Staff, Melanie Gavina and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2024
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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