445202851-2-22-2024-26-AS-SRAI-D2Q3C8-20240222170731

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 445202851
Report Date: 02/22/2024
Date Signed: 02/22/2024 05:07:47 PM

Document Has Been Signed on 02/22/2024 05:07 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 CORP		FACILITY NUMBER:	445202851
ADMINISTRATOR:	CHRISTINA RIVAS		FACILITY TYPE:	740
ADDRESS:	2177 17TH AVE		TELEPHONE:	(831) 475-1386
CITY:	SANTA CRUZ	STATE: CA	ZIP CODE:	95062
CAPACITY:	39	CENSUS: 22	DATE:	02/22/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Administrator, Saaj Kaiyom		TIME COMPLETED:	03:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit and met with Administrator (ADM) Saaj Kaiyom. LPA Rai observed 1 staff and 3 residents in the Dining Room #2. During visit, LPA Rai toured the inside and outside of the facility. LPA observed two (2) locked sheds in the backyard and they were not used as habitual space. When touring the outside area of the facility, the exits leading from the resident room to the outside were cleared of obstruction. LPA Rai observed the exit door (on the right side of the facility facing the main street 17th Ave) were not able to open. ADM unscrewed a bolt next to the handle which stopped the door from opening. LPA Rai observed a secondary fence approximately 4 feet high which also had a latch on the door and there was a screw next to the latch which stopped the door from opening. ADM stated there was a resident who would open the exit doors in the past. LPA Rai advised ADM to not substitute locked doors for supervision and exit doors needed to be able to open on their own and clear of obstruction. LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Sharps and medications were locked in secured areas. LPA observed additional food supply areas and secured areas for cleaning supplies and laundry detergents. LPA Rai toured the resident bedrooms. 8 out of 8 resident bedrooms had available bedding, drawers, and functioning lights. 3 out of 8 resident rooms did not have window screen or door screen in good repair. During the tour of the outside of the facility, ADM pointed out multiple rooms with door screen or window screen not in good repair. Continuation on LIC 809-C, Page 1 of 2.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024

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 4

Document Has Been Signed on 02/22/2024 05:07 PM - 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: PARADISE ASSISTED CARE CORP	FACILITY NUMBER: 445202851
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(a)

Medical Assessment

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interview, the licensee did not comply with the section cited above in 1 out of 5 resident's Physician's Report was not signed by physician and facility did not have a waiver for non-physician to sign doucments which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/29/2024
	Plan of Correction
1 2 3 4	Administrator stated to submit written plan of action regarding physicians signing medical assessments and understanding of regulation by POC due date.

Type B

Section Cited

CCR

87303(c)

(c) All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 3 out of 8 resident rooms had window screens and door screens which were not in good repair, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/29/2024
	Plan of Correction
1 2 3 4	Administrator stated to submit a written plan of action and understanding of regulations by POC due date.

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: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 02/22/2024 05:07 PM - 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: PARADISE ASSISTED CARE CORP	FACILITY NUMBER: 445202851
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87203

87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 2 out 3 fire exits were locked by a screw and not accessible which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/23/2024
	Plan of Correction
1 2 3 4	Administrator stated the written plan of action on how the exit doors will remain unlocked for the protection of life against fire and panic and understanding the regulation by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 CORP	FACILITY NUMBER: 445202851
	VISIT DATE: 02/22/2024

NARRATIVE

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The facility bathroom had available soap, paper towels, and trash cans with lids. The water temperature in the bathroom sinks ranged from 105.1F - 109.0F.

Fire extinguisher was observed and inspected on 03/29/2023. Facility carbon monoxide detectors were in working condition. Third party vendor inspected the fire alarm and sprinkler system on 1/10/2024 and the facility passed the inspection. The last disaster drill was conducted on 11/10/2023.

LPA Rai reviewed facility records for 5 staff and 5 residents. LPA Rai reviewed 1 out of 5 resident's Physician's Report was signed by a Physician's Assistant and not a Physician. Licensee stated they did not apply for a waiver for a non-physician to sign the Physician's Report and they do not plan on applying for a waiver. Licensee will work with R2's family to obtain a Physician's Report which is signed by a physician.

LPA Rai reviewed resident medications and central stored medication records. LPA observed first aid kit and evacuation chair on the second floor.

Deficiencies were cited per California Code of Regulations, Title 22, please see LIC 809-D. This report was reviewed with Administrator (ADM) Saaj Kaiyom and a copy of the report was provided. Appeal Rights were provided.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024

LIC809 (FAS) - (06/04)

Page: 4 of 4