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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202777
Report Date: 10/21/2021
Date Signed: 10/22/2021 08:53:07 AM

Document Has Been Signed on 10/22/2021 08:53 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:PADDINGTON ADULT RESIDENTIAL FACILITY INCFACILITY NUMBER:
435202777
ADMINISTRATOR:VALENZUELA, CECILIA SANOYFACILITY TYPE:
735
ADDRESS:1236 PADDINGTON WAYTELEPHONE:
(408) 770-9956
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY: 6CENSUS: 5DATE:
10/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Cecilia Valenzuela, ADMTIME COMPLETED:
02:29 PM
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At 12:40PM, Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with administrator (ADM) Cecilia Valnezuela.

Upon arrival, Caregiver Gregorio Locquiao (GL) took LPA's body temperature, and asked the screening questionnaires, then checked LPA in the visitor log book. COVID posters were observed in the facility. LPA toured the facility with GL. There are two staff live-in rooms in facility for 4 staff. There are 3 shared rooms for residents, and 2 restrooms in facility. Beds in the resident rooms were observed 6 feet apart. Two staff and three residents were observed in the facility. Two residents went out for day program. LPA toured the kitchen, dining room, family room, and garage. LPA observed that not all the trash cans with covers, and not all the paper towel with holders. ADM stated the facility will fix the issue today.

The room temperature was 76 degree F. And the hot water temperature was 106 degree F. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication closet was observed locked. Cleaning chemical products were observed locked. PPE supplies were observed sufficient. LPA toured backyard with ADM. No obstacles were observed blocked the walkway in the backyard. ADM's husband bought and brought the trash cans with food pedal cover when LPA was writing the report.

LPA reviewed the LIC808 with ADM. ADM stated all the staff and residents are fully vaccinated. ADM stated ADM is scheduling the booster for all residents and staff.

No deficiency or allegation was issued today. Exit interview was conducted with ADM. this report was provided to ADM for signature. A copy of this report was emailed to ADM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2021
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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