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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600998
Report Date: 05/14/2024
Date Signed: 05/14/2024 04:47:49 PM


Document Has Been Signed on 05/14/2024 04:47 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:PARADISE GARDENS CARE HOMEFACILITY NUMBER:
075600998
ADMINISTRATOR:LISING, ARSENIA E.FACILITY TYPE:
740
ADDRESS:686 MINERT ROADTELEPHONE:
(925) 944-9147
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:6CENSUS: 6DATE:
05/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Staff Marie RegachoTIME COMPLETED:
05:00 PM
NARRATIVE
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On 05/14/2024 at 9:00 AM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to conduct the Required Annual Inspection. Upon entry, LPA disclosed purpose of the visit to Staff Marie Regacho and met with Administrator Nenita Williams

The LPA inspected the interior and exterior of the facility, which included the kitchen, dining area, restrooms, community living spaces, resident rooms, storage areas, and the grounds of the facility. More than the required minimum of 7 days of nonperishable and 2 days of perishable foods were appropriately stored. Temperature in the dining room was measured at 71.4 degrees Fahrenheit at 10:37 AM. The LPA observed postings in the facility that included a complaint poster, Ombudsman and Personal Rights posters, Theft and Loss Policy, and Rights to Resident and Family Councils. The carbon monoxide and smoke detector were tested and found to be fully operational. The fire extinguisher was fully charged and replaced on 3/22/2024. An administrator is on site the minimum of 20 hours a week to oversee the proper business operations.

The LPA interviewed 2 staff members and 2 residents. The LPA reviewed records of 5 residents and 5 staff members.

During the inspection, 4 B-Type citations were issued (refer to LIC809-D for details). The annual inspection has not been completed. LPA will return unannounced to complete it on a future date.

Updated copy of the following document to be submitted to CCL on or before 05/28/2024:
  • Evidence of Current Liability Insurance

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 529-9416
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2024
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 4


Document Has Been Signed on 05/14/2024 04:47 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: PARADISE GARDENS CARE HOME
FACILITY NUMBER: 075600998

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87208(a)(7)(A)
87208 Plan of Operation (a) Each facility shall ... maintain ... current ... (7) Sketches ... (A) ... including a floor plan that describes the capacities of the buildings for the uses intended and a designation of the rooms to be used for nonambulatory residents and for bedridden residents....

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 1 facility sketches, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/28/2024
Plan of Correction
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On or before the due date, the Licensee shall submit an updated facility floor plan and yard sketch (LIC999) to CCL and inform the LPA of its submission.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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4
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: Harpreet HumpalTELEPHONE: (510) 529-9416
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/14/2024 04:47 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: PARADISE GARDENS CARE HOME
FACILITY NUMBER: 075600998

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(8)
Incidental Medical and Dental Care Services
(8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 1 first aid kits, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/28/2024
Plan of Correction
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On or before due date, Licensee shall ensure that a complete first aid kit is at the facility and inform the LPA that has been completed.
Type B
Section Cited
HSC
1569.695(a)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 1 Emergency/Disaster plans, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/28/2024
Plan of Correction
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On or before due date, Licensee shall create an Emergency/Disaster Plan and complete an up-to-date LIC610E (2019 version) and send a copy of it to the LPA.
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: Harpreet HumpalTELEPHONE: (510) 529-9416
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 05/14/2024 04:47 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: PARADISE GARDENS CARE HOME
FACILITY NUMBER: 075600998

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(e)(2)
Other Provisions
(e) A facility shall have all of the following information readily available to facility staff during an emergency: (2) An appraisal of resident needs and services plan for each resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out of 5 of the residents reviewed, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/28/2024
Plan of Correction
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On or before due date, Licensee shall ensure that an up-to-date LIC625 has been completed for every resident and inform the LPA that has been completed.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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4
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: Harpreet HumpalTELEPHONE: (510) 529-9416
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4