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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202843
Report Date: 01/29/2024
Date Signed: 01/29/2024 04:26:42 PM


Document Has Been Signed on 01/29/2024 04:26 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: 6DATE:
01/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator, Lynda Miguel and Direct Support Staff, Melanie GavinaTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit and met with Administrator, Lynda Miguel and Direct Support Staff, Melanie Gavina. LPA Rai observed 3 staff and 5 residents at the facility.

During visit, LPA Rai toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Sharps and medications were locked in secured areas. LPA observed additional food supply areas and secured areas for cleaning supplies and laundry detergents. LPA Rai toured the resident bedrooms. 3 out of 3 resident bedrooms had available bedding, drawers, and functioning lights.

The facility bathroom had available soap, paper towels, and trash cans with lids. The water temperature in the bathroom sinks ranged from 116.6F - 117.1F. The water temperature in the kitchen sink was 115.5F. LPA Rai observed the bathroom connected in a resident bedroom was locked. Per staff, the bathroom is not going through repairs and sometimes the residents use bathroom without staff's permission. LPA Rai checked bathroom sinks, toilet and shower in working condition. LPA Rai advised the staff to keep the bathroom door unlocked and accessible for residents to use.

Fire extinguisher was observed and inspected on 05/10/2023. Facility smoke detectors and carbon monoxide detectors were in working condition. The last disaster drill was conducted on 1/7/2024. LPA Rai reviewed facility records for 3 staff and 3 residents. LPA Rai reviewed resident medications and central stored medication records.

Deficiencies were cited per California Code of Regulations, Title 22, please see LIC 809-D. This report was reviewed with Direct Support Staff, Melanie Gavina. A copy of the report and Appeal Rights was provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2024
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 01/29/2024 04:26 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468.1(a)(3)
87468.1 Personal Rights of Residents in All Facilities

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in 1 out of the 2 bathrooms located in the resident room was locked and not accessible to the residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/30/2024
Plan of Correction
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Administrator will submit a plan of action, including in-service training with staff, and understanding of regulations by POC due date. Administrator agreed and understood.
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 ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2024
LIC809 (FAS) - (06/04)
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