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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801837
Report Date: 09/14/2021
Date Signed: 09/14/2021 10:29:52 AM

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 RESIDENTIAL CARE HOMEFACILITY NUMBER:
486801837
ADMINISTRATOR:GADIA, EDWARDFACILITY TYPE:
740
ADDRESS:524 AMERICANO WAYTELEPHONE:
(707) 344-4744
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:6CENSUS: 5DATE:
09/14/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Edward Gadia, AdministratorTIME COMPLETED:
10:40 AM
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On 9/14/21 LPA (Licensing Program Analyst) Lopez conducted an unannounced case management visit and was greeted by Administrator, Edward Gadia. LPA Lopez conducted a required annual visit on 9/10/21 that focused on inspection control. During annual inspection, LPA observed resident room had a desk which Administrator stated was also being used as facility office. Administrator agreed to move desk by 9/17/21. Technical Violation was issued during Case Management-Other inspection.

Exit interview was conducted. No deficiencies cited during today's Case Management-Other inspection.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Karen LopezTELEPHONE: (707) 588-5048
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021
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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