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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202851
Report Date: 03/08/2022
Date Signed: 03/09/2022 01:36:44 AM


Document Has Been Signed on 03/09/2022 01:36 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 ASSISTED CARE CORPFACILITY NUMBER:
445202851
ADMINISTRATOR:WILEY, ERIN ROSEFACILITY TYPE:
740
ADDRESS:2177 17TH AVETELEPHONE:
(831) 475-1386
CITY:SANTA CRUZSTATE: CAZIP CODE:
95062
CAPACITY:58CENSUS: DATE:
03/08/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Erin WileyTIME COMPLETED:
05:59 PM
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Licensing Program Analyst (LPA) Ryker Heberle conducted a pre-licensing inspection today. LPA met with Administrator Erin Wiley (Admin).

LPA toured the facility interior and exterior, receiving area, 10 resident bedrooms, 13 bathrooms, kitchen, lounge, upper lounge, dining area, library, laundry room, medication room, and backyard.

The facility is equipped with connected smoke detectors. 4 fire extinguishers was observed and were noted to have been inspected on March 8th 2021. The kitchen, dining, and living room were observed in good repair.

Resident bedrooms were observed to be in good repair. Bathrooms were observed clean and equipped with grab bars and non-skid mats. The water temperature was observed to be between 110* F and 115.1 F in all but one bedrooms. One bedroom noted to have a water temperature of 90*F. Central stored medication room was inspected and observed to be inaccessible to residents. First aid supplies noted to not contain tweezers. The backyard was inspected. All outdoor and indoor passageways were observed clear and free of obstruction. No bodies of water observed.

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 review of staff files, All staff members were noted to have to have cleared their criminal background check via guardian, however, 4 out of 10 staff files did not contain criminal background check clearance letter. Aforementioned 4 out of 10 staff did have notification of receipt of background check request.
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 10


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 ASSISTED CARE CORP
FACILITY NUMBER: 445202851
VISIT DATE: 03/08/2022
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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, however, repairman did not arrive before the end of the day

Component III orientation was waived for this facility due to Administrator’s prior experience. Facility licence approved pending completion of addressing all outstanding issues indicated in this report and pending the completion of Centralized Application Bureau (CAB) review of the facility application. Exit interview conducted with and copy of report provided to Erin Wiley
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
LIC809 (FAS) - (06/04)
Page: 2 of 10