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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803635
Report Date: 05/05/2023
Date Signed: 05/05/2023 12:01:08 PM

Document Has Been Signed on 05/05/2023 12:01 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: DATE:
05/05/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Ana Morales-Astroga, AdministratorTIME COMPLETED:
12:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced at Paradise Home for the purpose of conducting a Case Management - Deficiencies inspection. LPA met with Ana Morales-Astroga, Administrator. Licensee Selene Cruz-Astroga was also present.

LPA returned to issue citation and civil penalty due to former Staff (S1) who was fingerprint cleared but found not to be associated to the facility as required. S1 was involved in complaint investigation; complaint control #21-AS-20220323095522. S1 was sent to be fingerprinted and associated to the facility but due to an error of being fingerprinted with the Home Care Aide Registry, S1 was not associated to Paradise Home.

LPA explained prior to anyone working (including shadowing a staff and/or training), volunteering, residing or being present in any part of the licensed facility, they are required to be fingerprint cleared and associated to the facility. LPA explained Community Care Licensing (CCL) requirements and provided the regulation.
Licensee & Administrator stated they understood CCL's requirements and prior to anyone working, providing care, volunteering, or residing at a licensed facility, the individual must obtain a fingerprint clearance and be associated to the facility.

**An immediate civil penalty in the amount of $500 was assessed during today's inspection for S1 who was not associated to Paradise Home while providing care and supervision to clients.

Deficiencies cited (see LIC809-D page) from the California Code of Regulations (Title 22, Division 6). Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Appeal Rights Provided.

Exit interview conducted with Administrator Ana Morales-Astroga whose signature on this document confirms receipt.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2023
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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Document Has Been Signed on 05/05/2023 12:01 PM - It Cannot Be Edited


Created By: Karina Canela On 05/05/2023 at 10:16 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: PARADISE HOME
FACILITY NUMBER: 486803635

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/08/2023
Section Cited
CCR
80019(e)(2)

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80019 Criminal Record Clearance - (e) All individuals subject to a criminal record review ... shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 80019(f).
This requirement was not met as evidenced by:
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Administrator to submit a statement that they understand the regulation and will be in future compliance. All individuals are to be fingerprint cleared and associated prior to working, residing, volunteering, or being present in the facility. Administrator to submit their statement by POC due date 05/08/2023.
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Based on record review, Licensee did not ensure staff (S1) was associated to the facility as required. This is a potential health, safety and personal rights 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.
SUPERVISOR'S NAME:Hope DeBenedetti
LICENSING EVALUATOR NAME:Karina Canela
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2023


LIC809 (FAS) - (06/04)
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