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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803401
Report Date: 03/29/2022
Date Signed: 03/29/2022 11:18:51 AM


Document Has Been Signed on 03/29/2022 11:18 AM - 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 #2FACILITY NUMBER:
486803401
ADMINISTRATOR:GADIA, EDWARD & LOURDESFACILITY TYPE:
740
ADDRESS:3204 ARROYO DRIVETELEPHONE:
(707) 759-5088
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:6CENSUS: 5DATE:
03/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:32 AM
MET WITH:Administrator, Edward GadiaTIME COMPLETED:
11:30 AM
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At approximately 10:25AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct an Annual Inspection visit and was greeted by Staff Member, Danilo Rivera. Administrator, Edward Gadia, was available by telephone and arrived later during the visit. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival at the facility, LPA had their temperature checked and answered a standard COVID-symptom questionnaire. LPA conducted a walk-through of the facility and observed the following: COVID-19 signs were observed at the entry way and throughout the facility. Hand-washing signs were observed in the bathrooms and at sinks. All staff present were observed to be wearing a mask. The facility was found to be clean and at a comfortable temperature with all exits free from obstruction.

Facility has a cleaning and disinfecting schedule that occurs once per day. Facility has at least a 30-day supply of Personal Protective Equipment (PPE) and medication for residents. Staff and Residents are screened daily for COVID-19 symptoms and it is logged into facility binders.

LPA and Administrator discussed N-95 Fit testing, activities, and PPE. Facility has a plan in place if a staffing shortage were to occur.

Fire extinguishers were last serviced July 2021. Fire alarm system and carbon monoxide detectors were tested and operational.

No Deficiencies cited during this inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2022
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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