<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800368
Report Date: 12/27/2021
Date Signed: 12/27/2021 12:17:17 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:PARADISE VALLEY ESTATESFACILITY NUMBER:
486800368
ADMINISTRATOR:PEGGY HUSTONFACILITY TYPE:
741
ADDRESS:2600 ESTATES DRIVETELEPHONE:
(707) 432-1100
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:743CENSUS: 474DATE:
12/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Kelly Yee, Assisted Living ManagerTIME COMPLETED:
12:30 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) Karina Canela arrived unannounced to conduct an Annual Required - 1 Year inspection and met with Agatha Okuda, Deer Creek (Memory Care) Supervisor, and Kelly Yee, Deer Creek/Willow Creek/Quail Creek (Assisted Living) Manager. The annual inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly - Continuing Care Retirement Community (RCFE-CCRC).
Upon arrival LPA was screened at the front entrance for COVID-19 symptoms and to verify vaccination status. LPA was screened again for COVID-19 symptoms, including temperature check, and signed the visitor log at front entrance of both assisted living buildings per facility protocol. Staff and visitors are screened for COVID-19 symptoms, including temperature check, when entering the facility buildings and at front entrance. LPA observed COVID-19 precaution postings and conducted a walk-through of the memory care and assisted living buildings of the facility with Agatha and Kelly. The facility is in compliance with indoor visitation requirement of verifying COVID-19 vaccination or a negative COVID test within 72 hours for visitors. The facility has designated visitation areas, and provides virtual visits and phone calls for family to stay in contact with residents. Resident's temperatures are taken twice a day. High touched surface areas are disinfected after each use; staff clean and disinfect the facility throughout the day.
LPA verified documentation of staff training in the following categories: COVID-19 infection prevention, symptoms, transmission and PPE use. LPA verified N-95 respirator Fit testing (Cal/OSHA requirement) has been completed. The facility has an ample supply of PPE including gloves, face shields/goggles, N-95 respirators, surgical masks and disposable gowns. LPA verified documentation of staff vaccination status. All staff wore masks during the inspection visit.
The facility submitted a COVID-19 Mitigation Plan Report on Epidemic Outbreaks specific to COVID-19 which was reviewed by the California Department of Social Services, Community Care Licensing.

Exit interview conducted with Assisted Living Manager, whose signature on this document confirms receipt.
No deficiencies cited during this inspection
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina CanelaTELEPHONE: 707-588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2021
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 1