445202851-2-4-2022-26-AS-TDON-CBBRC5-20220204115346

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 445202851
Report Date: 02/04/2022
Date Signed: 02/04/2022 11:53:57 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814

FACILITY NAME:	PARADISE VILLA ASSISTED LIVING AND MEMORY CARE		FACILITY NUMBER:	445202851
ADMINISTRATOR:	WILEY, ERIN ROSE		FACILITY TYPE:	740
ADDRESS:	2177 17TH AVE		TELEPHONE:	(210) 724-2751
CITY:	SANTA CRUZ	STATE: CA	ZIP CODE:	95062
CAPACITY:	58	CENSUS: 27	DATE:	02/04/2022
TYPE OF VISIT:	Office	ANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Erin Wiley (Administrator) and Lusanta Kaiyom (Applicant)		TIME COMPLETED:	10:30 AM

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Facility Type: RCFE
Application Type: INC
Capacity: 58
Census (if any clients in care): 27
Method: Telephone at CAB
COMP II Participants: Erin Wiley (Administrator) and Lusanta Kaiyom (Applicant)

Applicant/Administrator participated in COMP II at CAB via telephone with analyst at CAB. Identification of the Applicant and Administrator was verified by providing California Driver License number. During COMP II, Applicant and Administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and Administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:

1. Facility operation: License type, client/resident populations, and program

2. Staff qualifications and responsibilities
3. Applicant and Administrator qualifications
4. Program policy: Abuse, admission agreement, medication management, reporting
incidents to CCL, restricted & prohibited conditions
5. Grievances, Complaints, Community resources
6. Physical plant, food service
Application document review and technical assistance: Criminal record clearance,
Health screening, Fire clearance, First Aid/CPR certificate, Administrator
certificate, Financial verification, Pre-licensing inspection, Compliance history,
Control of property

SUPERVISOR'S NAME: Julia Kim	TELEPHONE: (916) 651-7848
LICENSING EVALUATOR NAME: Thai Doan	TELEPHONE: (916) 651-1057
LICENSING EVALUATOR SIGNATURE:	DATE: 02/04/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2022

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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