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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800368
Report Date: 12/19/2022
Date Signed: 12/19/2022 03:32:30 PM


Document Has Been Signed on 12/19/2022 03:32 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:PARADISE VALLEY ESTATESFACILITY NUMBER:
486800368
ADMINISTRATOR:YEE, KELLYFACILITY TYPE:
741
ADDRESS:2600 ESTATES DRIVETELEPHONE:
(707) 432-1100
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:743CENSUS: 511DATE:
12/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Kelly Yee, AdministratorTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct an Annual Required - 1 Year inspection and met with Kelly Yee, Administrator. 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).
LPA and Administrator toured the assisted living and memory care buildings of the facility. All exits were observed unobstructed. The facility was found to be clean and at a comfortable temperature. Fire extinguishers were charged and serviced 02/08/2022. The facility has an ample supply of PPE. LPA observed COVID-19 precaution postings, liquid hand soap and paper towels available in bathrooms. Food supply is within regulation. The facility has designated visitation areas, and provides virtual visits and phone calls for family to stay in contact with residents. High touched surface areas are disinfected after each use; staff clean and disinfect the facility throughout the day. N-95 respirator Fit testing (Cal/OSHA requirement) has been completed. All staff wore masks during this inspection.

LPA requested the following updated forms to be submitted to Community Care Licensing by 01/19/2023:
· LIC 308 Designation of Facility Responsibility (1 person per form)
· LIC 500 Personnel Report
· LIC 400 Affidavit Regarding Client/Resident Cash Resources (indicate if not handling cash for residents)
· Copy of liability insurance
· LIC 610E Emergency Disaster Plan
· LIC 9020 Register of Facility Residents
· Copy of current Administrator's Certificate
· Copy of current Lease/Rental Agreement or Property Tax document showing control of property.

Exit interview conducted with Administrator, 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: 12/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2022
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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