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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803635
Report Date: 04/03/2023
Date Signed: 04/03/2023 03:15:08 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/03/2023 and conducted by Evaluator Karina Canela
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20230303090352
FACILITY NAME:PARADISE HOMEFACILITY NUMBER:
486803635
ADMINISTRATOR:ANA MORALES-ASTORGAFACILITY TYPE:
735
ADDRESS:3809 POPPY HILL COURTTELEPHONE:
(650) 387-9488
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:4CENSUS: 4DATE:
04/03/2023
UNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Ana Morales-Astroga, AdministratorTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Staff do not ensure there is an adequate food supply for clients

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to deliver findings on complaint 21-AS-20230303090352. LPA met with Ana Morales-Astroga, Administrator.

LPA investigated the above allegation. During the complaint investigation, LPA conducted interviews and inspected the facility, including the facility food supply in the pantry and in the two refridgerators (one located in the kitchen and one in the garage). Additionally LPA reviewed client's files, chart notes with daily food intake logs, and weight logs. LPA had requested and obtained copies of documents.

Report continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 21-AS-20230303090352
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 HOME
FACILITY NUMBER: 486803635
VISIT DATE: 04/03/2023
NARRATIVE
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The following was reported to the Community Care Licensing, Santa Rosa Regional Office:
    Paradise Home's food supply in the kitchen pantry and refrigerator were almost empty and would not last the clients a week.

Allegation: Staff do not ensure there is an adequate food supply for clients
Paradise Home management stated the facility was attempting to minimize food waste, therefore the food supply had been lower than usual. Interviews conducted with relevant parties also corroborated the allegation of a low food supply observed in the facility prior to LPA's visit on 03/07/2023. Administrator purchased a supply of groceries for Paradise Home during LPA's inspection on 03/07/2023 (photos taken). Additionally, LPA reviewed 4 of 4 client's food intake logs and weight logs. LPA observed client's had not lost a significant amount of weight (weight fluctuated within approximately 10 lb) between January - March 2023.

LPA conducted an on-site inspection at Paradise Home on 03/07/2023. LPA inspected the kitchen pantry and 2 of 2 refrigerators. LPA observed a food supply of nonperishable and perishable food for clients (photos taken). However, the facility food supply did not meet the regulation requirement of a supply of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

Based on LPA's observations on 03/07/2023 and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.


Appeal Rights Provided.
Deficiencies cited (see LIC9099-D page) from the California Code of Regulations (Title 22, Division 6 of California Regulation). Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.
Exit interview conducted with Administrator Ana Morales, whose signature below confirms receipt of report.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 21-AS-20230303090352
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 HOME
FACILITY NUMBER: 486803635
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/07/2023
Section Cited
CCR
85076(d)(1)
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85076 Food Service: (d)The licensee shall meet the following food supply and storage requirements:(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises. This requirement was not met as evidenced by:
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Administrator corrected food supply during 03/07/2023 inspection. Administrator to submit a self-certification form (LIC9098) and statement that they understand the regulation and will be in future compliance. LIC 9098 and statement to be submitted to Community Care Licensing (CCL) by POC due date 04/07/2023.
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Based on LPA observations and interviews conducted, Administrator did not ensure the regulation due to the facility not having a supply of food per regulation.
This is a potential health and personal rights care risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4