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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202851
Report Date: 07/06/2023
Date Signed: 07/06/2023 02:51:34 PM


Document Has Been Signed on 07/06/2023 02:51 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 ASSISTED CARE CORPFACILITY NUMBER:
445202851
ADMINISTRATOR:CHRISTINA RIVASFACILITY TYPE:
740
ADDRESS:2177 17TH AVETELEPHONE:
(831) 475-1386
CITY:SANTA CRUZSTATE: CAZIP CODE:
95062
CAPACITY:39CENSUS: 23DATE:
07/06/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:33 PM
MET WITH:Lusanta KaiyomTIME COMPLETED:
02:55 PM
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced case management inspection at the facility in response to an incident at the facility. LPA met with facility Administrator Lusanta Kaiyom (Admin). Incident occurred on Friday, June 30th, 2023. Facility fire alarms began going off at the facility at approximately 01:35pm, along with reports of the smell of smoke throughout the facility. Evacuation was estimated to have occurred over the course of 10 minutes. The fire department arrived at the facility and determined that there was no fire, and determined that the smell was coming from the facility furnace.

Fire department workers shut off the gas to the furnace and Admin unplugged it. During tour of the facility, LPA determined that there was no gas smell in the facility. LPA did not observe any fire damage within the facility. LPA observed the furnace and confirmed that the furnace was both unplugged and that the gas valve to the furnace was closed. LPA confirmed that the facility had received a quote from an electrician to replace the furnace.

LPA interviewed 7 facility residents. 7 out of 7 residents said that the evacuation was well organized and that they were not inconvenienced. 7 out of 7 residents stated that their care was not effected by the evacuation.

No deficiencies cited during this inspection. This report was reviewed with facility administrator Lusanta Kaiyom and a signed copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2023
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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