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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803401
Report Date: 03/28/2024
Date Signed: 03/28/2024 03:18:21 PM


Document Has Been Signed on 03/28/2024 03:18 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 #2FACILITY NUMBER:
486803401
ADMINISTRATOR:GADIA, EDWARD & LOURDESFACILITY TYPE:
740
ADDRESS:3204 ARROYO DRIVETELEPHONE:
(707) 759-5088
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:6CENSUS: 5DATE:
03/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Edward GadiaTIME COMPLETED:
03:28 PM
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LPA Hiratsuka conducted this unannounced annual visit. LPA toured with Administrator Edward Gadia.

This facility has six private resident rooms and two caregiver rooms. The backyard has a wood desk that is well maintained. There is an ample supply of perishable and nonperishable food supply. There is a locked cabinet for medications.

Several topics were discussed.

Today LPA obtained the following:
-LIC 200 application for a community care facility or residential care facility for the elderly license to change the fire clearance from five non-ambulatory to six non-ambulatory residents as well as an updated facility sketch. LPA shall submit a new fire clearance to the fire department.
-The LIC 200 also has the updated licensee mailing address to this address.

The following shall be updated and submitted to Community Care Licensing Division by April 17, 2024:
-LIC 308 designation of administrative responsibility
-current liability insurance
-LIC 500 facility personnel or staff schedule

No deficiencies cited.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2024
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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