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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801837
Report Date: 09/14/2023
Date Signed: 09/14/2023 03:10:31 PM


Document Has Been Signed on 09/14/2023 03:10 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 HOMEFACILITY NUMBER:
486801837
ADMINISTRATOR:GADIA, EDWARDFACILITY TYPE:
740
ADDRESS:524 AMERICANO WAYTELEPHONE:
(707) 344-4744
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:6CENSUS: 5DATE:
09/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Edward Gadia, Administrator & Ermie Rivera, House SupervisorTIME COMPLETED:
03:20 PM
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9/14/2023, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection visit for this facility and was greeted by House Supervisor, Ermie Rivera. Licensee, Edward Gadia was contacted and arrived later in the visit. The facility is licensed for six non-ambulatory and one bedridden resident and a hospice waiver for three. The facility currently provides care for five residents, one of which is receiving hospice services and some of which with a diagnosis of dementia.

LPA continued with a tour of the facility with House Supervisor and Administrator, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility exits were equipped with auditory alarms for residents with dementia. LPA observed one auditory alarm located in the common area in need of battery replacement. Licensee immediately ordered supply for replacement. Technical Violation issued. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 7/17/2023. Both smoke detectors and carbon monoxide detectors throughout the facility were interconnected, tested and found to be in working order. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations with food properly labeled. LPA observed a spoiled tomato located in the refrigerator which staff immediately removed. Licensee agrees to conduct a full check of all perishable food supplies to ensure all food supply is fresh. Technical Violation issued. Facility also follows appropriate dietary protocol for resident in care.

Toxins, sharps and other items that could pose threat if readily available to residents were kept secured under the kitchen sink, laundry closet and storage in the garage. Residents were observed engaging in discussion with staff, watching and interacting with game television shows or resting in their bedrooms. Residents appear to have a positive relationship with staff based on LPA observations.

Continued onto LIC809-C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2023
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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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
VISIT DATE: 09/14/2023
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There was a supply of hygiene products, continence products, paper products and clean linens available for residents. All resident bedrooms have lighting & appropriate furnishings. Medications are stored in a designated medication cart located in the dinning room and were found to be secured. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record. Upon count LPA found all administered medication to be in order. LPA also conducted a file review for all residents and found all resident records including physician's report and needs & service plans updated.

Licensee, Edward Gadia was unable to attend the full visit and left during inspection due to schedule appointments. LPA and House Supervisor reviewed and signed report. A copy of the report was printed for Licensee.

Licensee, Edward Gadia's Administrator Certificate 6022588740 is current and valid through 11/20/2024.

LPA requested the following documents be sent to CCL by COB 10/14/2023:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Liability Insurance
Control of Property

No deficiencies cited during today's visit
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023
LIC809 (FAS) - (06/04)
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