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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202559
Report Date: 05/27/2021
Date Signed: 07/21/2021 09:16:02 AM

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: 22DATE:
05/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Erin WileyTIME COMPLETED:
04:20 PM
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Licensing Progrm Analysts Ryker Heberle, and Eric Ng (LPAs) conducted an unannounced infection control site visit on 05/27/2021 at 2:00pm. LPAs met with facility administrator Erin Wiley (Admin).

LPAs toured the facility, including front room, 2 bathrooms, kitchen, dining room, living room, medicine room, 3 resident rooms, library and common area.

All staff members observed to be wearing masks.

Facility observed to have designated entry point for universal symptom screening with questionnaire. Facility staff observed to be conducting symptom screen on entry for visitors. All restrooms observed to be adequately stocked with paper towels, hand sanitizer, and hand soap. Bathrooms observed to not have foot pedal operated trash cans. LPAs reminded Admin to replace trash hand operated trash cans with foot pedal operated trash cans., Admin stated that they would replace the trash cans.

Facility observed to have adequate supply of PPE.

Advisory notes issued, see LIC 9102.

This report reviewed with Administrator Erin Wiley and a signed copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai NgTELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2021
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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