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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202843
Report Date: 01/06/2023
Date Signed: 01/06/2023 02:24:37 PM

Document Has Been Signed on 01/06/2023 02:24 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 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: 5DATE:
01/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:23 PM
MET WITH:Administrator Lynda Miguel and Direct Care Staff, Melanie Gavina TIME COMPLETED:
02:30 PM
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On 1/6/2023 @ 1:23pm, Licensing Program Analyst (LPA) Simi Rai conducted an unannounced annual inspection focusing on infection control. LPA Rai met with Administrator (ADM) Lynda Miguel and Direct Care Staff (DCS) Melanie Gavina. LPA Rai observed 2 client in the living room. Per DCS, 3 clients are at day program.

During visit, LPA Rai toured the facility to include the multi-purpose room, living room, 3 resident rooms, 1 staff room, 2 bathrooms, kitchen, laundry area, dining area and exterior. All fire exit routes are free and clear of obstruction. Toxins and sharp objects were secured. Medication stored in a locked cabinet.

Facility observed to have a designated central entry point to include a sign-in sheet and temperature check. Facility clean and disinfect as often as needed. Bathrooms supplied with hygiene products and hand washing sign. LPA Rai observed the trash can with lids. LPA Rai observed a sufficient amount of Personal Protective Equipment (PPE).

The following posters observed to include wash your hands, symptoms of COVID-19, social distancing and importance of wearing a mask.

LPA Rai observed the laundry room to have kitchen area, including a sink, stove and fridge. LPA Rai observed Room #3 is a resident room and Room #2 is a staff room. Administrator will submit new facility floor plan to LPA Rai by Friday, January 13, 2023.

No deficiencies were cited per California Code of Regulations, Title 22.

This report was reviewed with Direct Care Staff Melanie Gavina and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 01/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/06/2023
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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