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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202843
Report Date: 12/21/2021
Date Signed: 12/21/2021 03:42:28 PM

Document Has Been Signed on 12/21/2021 03:42 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:PARADISE MANOR II INC.FACILITY NUMBER:
435202843
ADMINISTRATOR:MIGUEL, LYNDAFACILITY TYPE:
740
ADDRESS:19133 MURIEL LN.TELEPHONE:
(408) 836-0828
CITY:CUPERTINOSTATE: CAZIP CODE:
95014
CAPACITY: 6CENSUS: 0DATE:
12/21/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Linda Miguel, ADMTIME COMPLETED:
02:55 PM
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Licensing Program Analyst (LPA) Steve Chang conducted a pre licensing inspection visit, and met with administrator (ADM) Linda Miguel. Upon arrival, staff Melanie Gavina (MG) took LPA's body temperature, asked the infection control questionnaires, and checked LPA in guest book. ADM stated there is no residents in the facility. This facility address is currently licensed as a Adult Residential Facility (# 435202797). SARC is currently reviewing vendorization for RCFE application. LPA also informed applicant who also is the licensee of ARF (#435202797) to submit a letter of facility closure once this RCFE facility has been licensed.

LPA toured the facility inside out with ADM. There are 3 shared bedrooms for residents, 1 bedroom for staff, and 2 restrooms in facility. Living room, family room, kitchen, laundry area and dinning area were observed in good repair. Not all trash cans were with covers. Not all paper towels with holder. ADM stated the facility will fix this issue in 2 days. ADM stated the facility will setup a screening station with PPE and visitor log book in 2 days. ADM stated facility will put the grab bars and non-skid mats in restrooms in two days. Room temperature was observed at 70 degree F, and hot water temperature was measured at 117 degree F. The facility is equipped with smoke and carbon monoxide detectors. ADM tested smoke and carbon monoxide detectors, and they were working fine. Fire extinguisher was observed, and was serviced on 04/10/2021. Medication closet, knives closet, and cleaning product closet were observed locked. PPE supplies were observed sufficient. LPA inspected backyard. There is no obstruction to block the walkway.

ADM stated all staff were fully vaccinated and done with booster shots. Component III orientation was completed with ADM. No issues noted during inspection. Exit interview 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: 12/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2021
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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