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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803635
Report Date: 06/20/2023
Date Signed: 06/20/2023 04:52:44 PM

Document Has Been Signed on 06/20/2023 04:52 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 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:
06/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:43 PM
MET WITH:Ana Morales-Astroga, AdministratorTIME COMPLETED:
05:02 PM
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Licensing Program Analyst (LPA) Karina Canela arrived for the purpose of conducting a Required -1 Year inspection and met with Ana Morales-Astroga, Administrator.
LPA toured the facility, all exits were unobstructed. The facility was found to be clean & at a comfortable temperature. LPA observed a supply of PPE, emergency supplies, linens (bedding, towels, etc.), and cleaning solutions (observed locked). Liquid hand soap and paper towels are available in 2 of 2 bathrooms. Client's bedrooms were fully furnished per regulation. Medication was centrally stored. Water temperature was tested and observed between 105 to 120 degrees F as required.
Quarterly Disaster Drills are conducted as required. Fire extinguisher were charged and serviced 11/23/2022. There are 10 hardwired combination smoke & carbon monoxide detectors which were tested and observed operational. LPA reviewed staff and client records. Staff have current training certifications in First Aid & Cardiopulmonary Resuscitation (CPR) in file. Client files are complete and up-to-date.

LPA requested the following updated forms to be submitted to Community Care Licensing by 07/30/2023:
· LIC 308 Designation of Facility Responsibility (1 person per form)
· LIC 500 Personnel Report
· LIC 400 Affidavit Regarding Client/Resident Cash Resources (indicate if not handling cash for residents)
· Copy of Surety Bond
· LIC 9020 Facility Register of Client/Residents
· LIC 610D Emergency Disaster Plan
· Copy of current Administrator's Certificate

Exit interview conducted with Administrator, whose signature on this document confirms receipt.
***No deficiencies cited during this inspection
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2023
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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