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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803635
Report Date: 06/14/2024
Date Signed: 06/14/2024 04:02:17 PM

Document Has Been Signed on 06/14/2024 04:02 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 HOMEFACILITY NUMBER:
486803635
ADMINISTRATOR/
DIRECTOR:		ANA MORALES-ASTORGAFACILITY TYPE:
735
ADDRESS:3809 POPPY HILL COURTTELEPHONE:
(650) 387-9488
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 4DATE:
06/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Anna Morales, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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At approximately 10:00 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and was greeted by Anna Morales, Administrator. Licensee of C.A.S.A. LUNA, INC., Selene Cruz was contacted and informed Administrator to proceed with inspection and Licensee arrived shortly after. Facility is an Adult Residential Facility with Ambulatory Developmentally Disabled Clients in care. LPA was informed that there are 4 clients in care; 3 clients were away at Day Program, and 1 client was present during visit.

At approximately 10:15 AM, LPA initiated a tour of the facility with Administrator and observed the following: Facility is a one-story home, was a comfortable temperature, and passageways were free from obstructions. Water temperature in clients' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of clean linens and paper products available to clients. Clients' bedrooms were inspected and observed to have appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked. Facility has at least two days of perishable food and one week of non-perishable foods. Facility also has a sufficient emergency water supply. Medications were centrally stored and locked. There is a covered deck and outdoor space for activities in the backyard. LPA observed a supply of games for clients and holiday and party supplies which LPA was informed are used to host combined holiday parties with clients from other facilities within the organization.

Facility's fire extinguisher was observed charged and last serviced November 2023. Facility is hardwired with internal fire doors in place and smoke and carbon monoxide detectors which were all tested and observed operational during inspection. Facility conducts regular quarterly emergency and disaster drills with the most recent drill conducted April 2024. LPA observed an infection control plan and emergency disaster plan updated in 2023. LPA observed a supply of PPE, emergency supplies, and flashlights, as well as a first aid kit. Administrator states the facility does not have a backup generator.

Continued on LIC809-C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2024
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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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 HOME
FACILITY NUMBER: 486803635
VISIT DATE: 06/14/2024
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Continued from LIC809...

At approximately 11:15 AM, LPA reviewed 5 staff files and 4 client files. 4 of 5 staff files reviewed have the required First Aid certificates. 4 of 5 has current CPR certification as well. 1 of 5 staff have CPR and First Aid which expired on 6/6/2024. LPA informed that this staff member always works with other staff who do have current certifications and this staff member was enrolled in a CPR and First Aid renewal training during today's visit. Administrator agrees to submit proof of completion to CCL upon receipt. LPA also observed 1 of 5 staff files missing LIC503 Employee Health Screening and cited this deficiency during today's inspection (see LIC 809-D). Administrator to complete plan of correction (POC) by due date of 6/24/2024. LPA observed that 5 of 5 staff files have all the remaining required paperwork in their files. 4 of 4 client files had the required paperwork per regulation. Administrator coordinates medical and dental visits for the clients and takes them to their appointments.

At approximately 1:30 PM, LPA reviewed medications and medication records which are maintained in compliance with regulation. However, LPA observed fill dates not accurately reflecting the prescription label. LPA informed Administrator of proper recording procedures. LPA reviewed P&I monies and logs, which were organized and maintained according to regulation. Review of facility's Surety Bond showed that client P&I exceeds the amount covered on the Surety Bond. LPA discussed with Administrator the need to increase the surety bond amount.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 10 days of this visit:

Continued on LIC809-C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024
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 HOME
FACILITY NUMBER: 486803635
VISIT DATE: 06/14/2024
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LPA requested the following updated forms to be submitted to Community Care Licensing by 06/24/2024:
· LIC 500 Personnel Report
· LIC 610D Emergency Disaster Plan
· LIC 9020 Register of Facility Clients
· LIC 9282 Infection Control Plan
- Administrator self-certification regarding proper maintenance of Centrally Stored Medication Records
- LIC 400 Affidavit Regarding Client/Resident Cash Resources (to reflect accurate amount of cash that is being
safeguarded)
· Copy of Surety Bonds (to reflect accurate amount of cash that is being safeguarded)
- LIC503 Employee Health Screening signed by a physician

The following deficiency was observed (see LIC 809-D) and cited 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 and appeal of rights provided. Signature on form confirms receipt.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/14/2024 04:02 PM - It Cannot Be Edited


Created By: Julie Florio On 06/14/2024 at 03:43 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: PARADISE HOME
FACILITY NUMBER: 486803635

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 out of 5 staff records reviewed which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/24/2024
Plan of Correction
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Adminstrator to submit staff LIC 503 Health Screening signed by a physician by POC due date 6/24/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Julie Florio
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2024


LIC809 (FAS) - (06/04)
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