<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202777
Report Date: 10/23/2024
Date Signed: 10/23/2024 04:12:21 PM

Document Has Been Signed on 10/23/2024 04:12 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:PADDINGTON ADULT RESIDENTIAL FACILITY INCFACILITY NUMBER:
435202777
ADMINISTRATOR/
DIRECTOR:		VALENZUELA, CECILIA SANOYFACILITY TYPE:
735
ADDRESS:1236 PADDINGTON WAYTELEPHONE:
(408) 770-9956
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY: 6CENSUS: 6DATE:
10/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:52 AM
MET WITH:Jalano ValenzuelaTIME VISIT/
INSPECTION COMPLETED:
12:23 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with House manager (HM) Jalano Valenzuela.

LPA observed 1 residents and 3 staff in the facility. LPA checked 3 resident files and 3 staff files.

LPA toured the facility with HM. License, Administrator Certificate and Personal right posters were observed in the facility. There are one staff break room in the facility, 2 resident shared rooms, 2 resident single room, and 2 restrooms in the facility. Grabbing bars and Non skid mats were observed in the bathrooms. 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 72 degree F, and the hot water temperature was 119 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 was observed unlocked. The facility locked it immediately. Knives cabinet was observed locked. Fire extinguisher was serviced on 10/17/2024. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by HM, 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 10/3/2024.

LPA toured backyard with HM. No obstacles were observed blocked the walkway in the backyard. A storage room was observed in the backyard.

Deficiency noted today. See LIC809-D. Exit interview was conducted with HM. The report was provided to HM for signature. A copy of the report was provided to HM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2024
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 10/23/2024 04:12 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 10/23/2024 at 12:02 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: 10/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(k)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in that a resident R1's centrally stored medications from was observed not accurate and not up to date which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/30/2024
Plan of Correction
1
2
3
4
House Manager stated to submit a plan of correction by the POC due date to provide the training to staff to ensure the centrally stored mediation forms are maintain accurate, and to send the staff training log to CCL office.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: 10/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2024


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