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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800368
Report Date: 10/26/2023
Date Signed: 10/26/2023 01:14:39 PM


Document Has Been Signed on 10/26/2023 01:14 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
SANTA ROSA RO, 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: 70DATE:
10/26/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Elvira Gabionza (RN) MDS CoordinatorTIME COMPLETED:
01:40 PM
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Licensing Program Analyst (LPA) Carol Fowler arrived at Paradise Valley Estates on 10/26/2023 for the purpose of completing a Required – 1 Year inspection and was granted access into the facility. LPA met with Agatha Narvaez-Okuda (LVN) Memory Care Supervisor.

LPA conducted file review for staff and residents. LPA reviewed a sample of three (3) resident records from Quail Creek AL, three (3) resident records from Willow Creek AL and four (4) resident records from Deer Creek MC. LPA reviewed a sample of three (3) staff files from Quail Creek AL, three (3) staff files from Willow Creek AL and four (4) staff files from Deer Creek MC. Staff files reviewed have required First Aid and CPR certificates. Resident's files have medical assessments updated.


LPA requested copies to be submitted by 11/3/2023:

LIC500- Personnel Report
LIC308- Designation of Responsibility
Evidence of Liability Insurance
LIC610E- Disaster Plan
Updated Infection Control Plan


LPA will return to conducted staff and resident interviews.
No deficiencies cited during inspection
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: 707-588-5053
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2023
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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