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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202777
Report Date: 10/24/2023
Date Signed: 10/25/2023 08:07:49 AM

Document Has Been Signed on 10/25/2023 08:07 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: 6DATE:
10/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:39 PM
MET WITH:Cecilia ValenzuelaTIME COMPLETED:
04:48 PM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) Cecilia Valnezuela.

LPA checked 5 resident files and 5 staff files.

LPA toured the facility with ADM. License, Administrator Certificate and Personal right posters were observed in the facility. There are two staff live-in rooms, 3 resident shared rooms, and 2 restrooms in the facility. Grabbing bars and Non skid pads were observed in the bathrooms. 3 staff and 5 residents were observed in the facility. LPA toured the kitchen, dining room, family room, and garage. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. The room temperature was 74 degree F, and the hot water temperature was 110 degree F. The temperature of the refrigerator was measured at 33 degree F, and the temperature of freezer was measured at -5 degree F. Medication cabinet was observed locked. Cleaning chemical products cabinet under the sink were observed locked. Knives cabinet was observed locked. Fire extinguisher was serviced on 10/24/2023. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were working fine. First aid box, flash light for emergency, and night light were observed in the facility. The facility fire and emergency drill was conducted on 10/5/2023.

LPA toured backyard with ADM. No obstacles were observed blocked the walkway in the backyard. Gnats were observed around the garbage cans placed at the side yard by the building of the facility.

ADM agreed to update the Infection Control Plan and send to LPA. Deficiencies were noted today. See LIC809-D.

Exit interview was conducted with ADM. The report was provided to ADM for signature. A copy of the report was provided to ADM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2023
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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Document Has Been Signed on 10/25/2023 08:07 AM - It Cannot Be Edited


Created By: Chihhsien Chang On 10/24/2023 at 04:25 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: PADDINGTON ADULT RESIDENTIAL FACILITY INC
FACILITY NUMBER: 435202777

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)(1)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (1) The licensee shall take measures to keep the facility free of flies and other insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, gnats were observed around the garbage cans placed at the side yard by the building of the facility, Administrator did not comply with the section cited above which poses/posed a potential health risk to persons in care.

], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2023
Plan of Correction
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Administrator stated to submit a Plan of Correction by the POC due date to clean up the side yard area.
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:Romeo Manzano
LICENSING EVALUATOR NAME:Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2023


LIC809 (FAS) - (06/04)
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