<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803635
Report Date: 09/03/2021
Date Signed: 09/03/2021 12:32:10 PM

Document Has Been Signed on 09/03/2021 12:32 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:PARADISE HOMEFACILITY NUMBER:
486803635
ADMINISTRATOR:TAGUPA, MARIA CARLAFACILITY TYPE:
735
ADDRESS:3809 POPPY HILL COURTTELEPHONE:
(650) 387-9488
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 4DATE:
09/03/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Selene Cruz-Astroga, LicenseeTIME COMPLETED:
12:40 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
Licensing Program Analyst (LPA) Karina Canela conducted an unannounced case management inspection and met with Selene Cruz-Astroga, Licensee. The purpose of this case management inspection is to follow up on an incident which was self reported to LPA on 08/20/2021 by telephone. An incident report was submitted to Community Care Licensing (CCL) on 08/23/2021.
The following was reported: On 08/20/2021 at approximately 8:30 AM Staff (S1) was preparing medication for the clients. S1 prepared Client (C1)'s medication in a medication cup with C1's initials on the bottom of the cup. S1 left the medication cup on the counter to grab a glass of water for C1. S1 then gave C1's medication (2 medications) to Client (C2) by mistake. Staff realized the mistake immediately and contacted Paradise Home's Nurse Consultant, who advised to contact C2's medical physician. Staff contacted C2's psychiatrist who advised C2 be taken to urgent care. C2 did not display an immediate reaction to the medication. C2 was taken to urgent care at North Bay Medical at approximately 9:00 AM and was discharged at 10:30 AM due to no signs of toxic effect. C2's hospital discharge paperwork (copy provided to CCL on 08/23/2021) indicated C2 was evaluated and treated for "Accidental Ingestion: Nontoxic (Adult)". Paradise Home staff were advised by C2's psychiatrist to continue C2's medication for the day. North Bay Medical Center discharge notes stated to hold C2's medication for the rest of the day. Staff followed NBMC's written report and held C2's medications for the day.
During today's inspection LPA reviewed S1's initial medication training and DSP training (which includes medication training). Licensee provided re-training on medication on 08/20/2021 for S1 and 2 staff who were present during the incident. Licensee provided re-training on medication to all staff on 08/21/2021. Staff will focus on their medication set-up, staff communication/reminders, and limit distractions.
In addition to the self-reported incident, immediate action taken, and medication training provided, S1 was suspended for 3 days.
Appeal Rights Provided.
Deficiencies cited (see LIC809-D page) from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiencies and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Licensee Selene Cruz-Astroga, whose signature below confirms receipt of report.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 09/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 09/03/2021 12:32 PM - It Cannot Be Edited


Created By: Karina Canela On 09/03/2021 at 10:45 AM
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
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: PARADISE HOME
FACILITY NUMBER: 486803635

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/08/2021
Section Cited
CCR
80075(b)

1
2
3
4
5
6
7
80075 Health Related Services: (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.
** This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee to provide an overview/refresher of medication training to Staff (S1) to ensure future compliance to regulation 80075(b) Proof of training to be submitted to Community Care Licensing by POC due date 09/08/2021.
8
9
10
11
12
13
14
Based on records reviewed and interviews conducted, Licensee did not ensure the regulation above due to Staff (S1) who mistakely gave Client (C1)'s medication to C2.
This is a potential health and safety risk to clients in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Karina Canela
LICENSING EVALUATOR SIGNATURE:
DATE: 09/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2021


LIC809 (FAS) - (06/04)
Page: 2 of 2