486803401-3-14-2025-21-AS-RFRK-DERVQ4-20250314163745

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803401
Report Date: 03/14/2025
Date Signed: 03/14/2025 04:37:55 PM

Document Has Been Signed on 03/14/2025 04:37 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 RESIDENTIAL CARE HOME #2		FACILITY NUMBER:	486803401
ADMINISTRATOR/ DIRECTOR:	GADIA, EDWARD & LOURDES		FACILITY TYPE:	740
ADDRESS:	3204 ARROYO DRIVE		TELEPHONE:	(707) 759-5088
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94533
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	03/14/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:00 PM
MET WITH:	Edward Gadia, Administrator		TIME VISIT/ INSPECTION COMPLETED:	04:50 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	At approximately 1:00 PM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Required 1 Year visit and was greeted by Caregiver Danilo Rivera. Administrator Edward Gadia arrived at 1:10 PM. Paradise Valley Residential Care Home #2 is Licensed as a Residential Care Facility for the Elderly (RCFE). The facility is a single story ranch house. The facility has an approved fire clearance for six (6) residents. Five (5) of the residents may be non-ambulatory The facility has a Hospice Waiver for three (3) residents. The facility has a Dementia Program on file. Upon arrival, LPA was informed that there were five (5) residents in care and three (3) staff members, including the Administrator on-site. At approximately 1:15 PM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 1:20 PM, LPA toured the facility with Administrator Gadia. All exits were clear and unobstructed. Facility had one (1) fire extinguishers which was last serviced and tagged on 7/5/2024. Food supply was sufficient. The facility was sufficiently lighted. LPA inspected five (5) resident bedrooms and found all to have sufficient lighting and furnishings as required per Title 22 Regulations. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Toxins were observed to be stored inaccessible to residents. Facility has an infection control plan as required. The facility has a required emergency disaster plan. The facility is conducting fire and emergency drills quarterly. The last disaster drill was conducted on 3/10/2025. The facility does have emergency food and supplies to meet the "72 hour shelter in place" requirements. Hot water temperatures for all sinks in facility were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. Facility smoke detectors and carbon monoxide detectors were tested and observed to be operational. Continued on 809-C

Victoria Bertozzi	TELEPHONE: (707) 588-5059
Robert Frank	TELEPHONE: (707) 588-5026
	DATE: 03/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025

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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: PARADISE VALLEY RESIDENTIAL CARE HOME #2	FACILITY NUMBER: 486803401
	VISIT DATE: 03/14/2025

NARRATIVE

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...Continued from 809

At approximately 2:00 PM, LPA reviewed four (4) resident files. Four (4) of four (4) resident files were found to be well organized and thorough with all required documentation. LPA reviewed three (3) staff files. All staff files had First Aid and CPR certification and proper training documentation. LPA observed that two (2) staff files, for S1 & S2, they did not have proof of a negative Tuberculosis test on file. One (1) staff file, for S3, did not have Tuberculosis test on file. In addition LPA observed that for S3, the medical assessment was not signed by an authorized health care representative. This deficiency will be cited. LPA spot checked Medication for four (4) residents. LPA observed all medications to be centrally stored, secure and with proper documentation. The facility does not handle resident’s monies for personal and incidental items.

Edward Gadia’s Administrator Certification 7006929740 is current with an expiration date of 11/20/2026.

Lourdes Gadia's Administrator Certification 7006158740 is current with an expiration date of 10/20/2026.

LPA requested the following documents be submitted to Community Care Licensing by 4/14/2025:

LIC 500 Personnel Report

LIC 308 Designation of Responsibility
LIC 610E Emergency Disaster Plan
Proof of Liability Insurance

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC-809D, Plan of Corrections, 811 Confidential Names and Appeal Rights discussed and provided to Administrator Gadia. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Robert Frank	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 03/14/2025 04:37 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: PARADISE VALLEY RESIDENTIAL CARE HOME #2	FACILITY NUMBER: 486803401
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87411(f)

Personnel Requirements - General

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in that three (3) staff members, S1, S2 and S3 did not have proof of a negative Tuberculosis test on file. In addition LPA observed that for S3, the medical assessment was not signed by an authorized health care representative which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/14/2025
	Plan of Correction
1 2 3 4	Administrator will Submit to Community Care Licensing proof of negative Tuberculosis for S1, S2 and S3 by POC Due Date of 4/14/2025. Administrator will also submit a medical assessment for S3 that is signed by an authorized health care representative by POC due date of 4/14/2025.

Section Cited

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Victoria Bertozzi	TELEPHONE: (707) 588-5059
Robert Frank	TELEPHONE: (707) 588-5026
	DATE: 03/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025

LIC809 (FAS) - (06/04)

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