486801837-10-29-2024-21-AS-MCUA-DAHQME-20241029121724

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486801837
Report Date: 10/29/2024
Date Signed: 10/29/2024 12:17:33 PM

Document Has Been Signed on 10/29/2024 12:17 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 RESIDENTIAL CARE HOME		FACILITY NUMBER:	486801837
ADMINISTRATOR/ DIRECTOR:	GADIA, EDWARD		FACILITY TYPE:	740
ADDRESS:	524 AMERICANO WAY		TELEPHONE:	(707) 344-4744
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94533
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	10/29/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Erminda Rivera (House Supervisor)		TIME VISIT/ INSPECTION COMPLETED:	12:32 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) Cuadra arrived unannounced to conduct an annual required – 1 yr. inspection visit for this facility and was greeted by House Supervisor, Erminda Rivera. Annual fees are current. Required postings were observed. Contact information was reviewed. LPA/House Supervisor initiated a tour of the facility approximate at 9:45am and observed the following: facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Water measured 109.2 and 108.5 degrees F which is within regulation. Auditory alarms were found operational. Resident’s bedrooms were furnished per regulation. Fire Extinguisher was found to be last charged on 7/17/24. Smoke detectors and carbon monoxide detectors throughout the facility were tested and found to be in operational. There was not sufficient supply of perishable food, LPA/House Supervisor observed three grapefruit, 1 cauliflower, half of cucumber, bag of celery, one lettuce and one cabbage in the refrigerator (photos taken). According to house manager, tomorrow is grocery shopping day. LPA had a discussion with staff about the importance to ensure at all times that residents have supplies for three snacks between meals. There was adequate supplies of nonperishable foods handled and stored per regulation. Toxins, sharps and other items that could pose threat were inaccessible to residents. There was a supply of hygiene products, continence products, paper products and clean linens available for residents. Disaster drill has not been conducted and documented within the last quarter. LPA initiated file review at 10:15am of six residents and three staff files. All resident's files have current medical assessments and care plans. All staff have current CPR/1st aid certificates and training hours complete. Medications and medication records were reviewed. Edward Gadia's Administrator Certificate 6022588740 expires on 11/20/2024. LPA was provided with the following documents: LIC 308 Designated Facility Responsibility, LIC 500 Personnel Summary. House Supervisor agreed to submit the following by 11/8/24: Copy of liability Insurance and control of property. Deficiencies are cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted with House Supervisor and a copy of this report was given.

Bethany Moellers	TELEPHONE: (707) 588-5040
Marisol Cuadra	TELEPHONE: (707) 588-5078
	DATE: 10/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024

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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Document Has Been Signed on 10/29/2024 12:17 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: PARADISE VALLEY RESIDENTIAL CARE HOME	FACILITY NUMBER: 486801837
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87555(b)(26)

General Food Service Requirements

(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's/House Supervisor observation, interview and record review, the licensee did not comply with the section cited above by not having a enough supply of fruits and vegetables which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/30/2024
	Plan of Correction
1 2 3 4	The facility agrees to submit pictures of replenished food supply in a sufficient amount for residents in care. Submit copy of food receipt as well. Submit how Licensee is ensuring food supply will be sufficient in the future. Plan of correction due 10/30/24.

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: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/29/2024 12:17 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: PARADISE VALLEY RESIDENTIAL CARE HOME	FACILITY NUMBER: 486801837
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's/House Supervisor observation, interview and record review, the licensee did not comply with the section cited above by not conducting/documenting a disastir drill within the last quarter, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/08/2024
	Plan of Correction
1 2 3 4	Licensee agrees to conduct and document disaster drills every 3 months on all shifts with all direct care staff. Licensee agrees to conduct a disaster drill on all shifts with all direct care staff and submit proof to CCL by POC due date 11/8/24.

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: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024

LIC809 (FAS) - (06/04)

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