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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202559
Report Date: 03/08/2022
Date Signed: 03/09/2022 01:34:14 AM


Document Has Been Signed on 03/09/2022 01:34 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:PARADISE VILLAFACILITY NUMBER:
445202559
ADMINISTRATOR:ERIN ROSE WILEYFACILITY TYPE:
740
ADDRESS:2177 17TH AVENUETELEPHONE:
(831) 475-1380
CITY:SANTA CRUZSTATE: CAZIP CODE:
95062
CAPACITY:58CENSUS: 26DATE:
03/08/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Erin WileyTIME COMPLETED:
05:59 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ryker Heberle conducted a pre-licensing inspection today. LPA met with Administrator Erin Wiley (Admin). During pre-licensing inspection, LPA noted multiple deficiencies.

During review of resident files, LPA noted that 4 out of 10 resident records reviewed did not have a signed pre-appraisal or needs and services plan. 1 out of 10 records inspected did not have a signed admissions agreement. 1 out of 10 records inspected did not have.a signed physician's report.

During tour of the facility, LPA noted that room 2 of the facility had a bedridden resident residing in it, despite room 2 not being outlined on the fire safety inspection as a room that permits bedridden residents. Facility also noted not to have evacuation chairs located at each stairwell. During audit of med room, it was noted that the facility does not have its own pair of tweezers. Facility med tech possessed a pair of tweezers, but indicated that they were her personal tweezers.

During tour, it was noted that facility drying machine was currently non-operational. Clothes and towels were noted to be in the process of air drying. Admin indicated that the dryer broke that morning, and that a repair man had been enlisted to repair it before the end of the day.

Deficiencies cited. See 809-D for details. Report was reviewed with Administrator Erin Wiley and a copy of this report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2022
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 3


Document Has Been Signed on 03/09/2022 01:34 AM - 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131


FACILITY NAME: PARADISE VILLA
FACILITY NUMBER: 445202559

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/09/2022
Section Cited

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87606 - Care of Bedridden Residents - (c) To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a). This requirement was not met as evidenced by:
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Based on LPA observation, a resident was noted to be residing in a room that the fire and safety inspection request indicated as not allowing bedridden residents, which poses an immediate safety risk to residents in care.
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Type B
03/15/2022
Section Cited

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87506 - Resident Records - The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility... This requirement was not met as evidenced by:
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Based on records review, 5 out of 10 records reviewed contained incomplete documents with missing signatures of responsible parties or physicians. This posed a potential health and safety risk to residents in care
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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: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 03/09/2022 01:34 AM - 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131


FACILITY NAME: PARADISE VILLA
FACILITY NUMBER: 445202559

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/15/2022
Section Cited

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87303(g)(1) - Maintanance and Operation - (g) Facilities which have machines and do their own laundry shall: (1) Have adequate supplies available and equipment maintained in good repair. This requirement was not met as evidenced by:
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Based on LPA observation, the facility drying machine was nonoperational. This posed a potential risk to the health and safety of residents in care
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Type B
03/15/2022
Section Cited

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87465 - Incidental Medical and Dental Care - ...(8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained... The kit... shall contain at least the following: (E) Tweezer. this requirement was not met as evidenced by:
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Based on LPA observation, the facility first aid kit did not contain tweezers, this posed a potential health and safety risk to residents in care.
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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: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3