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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601215
Report Date: 12/22/2023
Date Signed: 12/22/2023 04:23:24 PM


Document Has Been Signed on 12/22/2023 04:23 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 HOME IIFACILITY NUMBER:
075601215
ADMINISTRATOR:LISING, ARSENIA E.FACILITY TYPE:
740
ADDRESS:197 LOS CERROS AVENUETELEPHONE:
(925) 944-9147
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:6CENSUS: 5DATE:
12/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Caregiver Marie RegachoTIME COMPLETED:
04:36 PM
NARRATIVE
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On 12/22/2023 at 12:35 PM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to conduct the Required Annual Inspection of the facility. Upon arrival, LPA stated the purpose of the visit to Caregiver Marvin Obuyes. Licensee/Administrator (ADM) Arsenia "Zeny" Lising was notified immediately thereafter but unable to come to facility in person. Caregiver Marie Regacho arrived at approximately 2:05 PM.

LPA toured facility inside and outside. All outdoor and indoor passageways were free of obstruction. There were no bodies of water observed. Inside, the temperature was measured at 71.4 degrees and the hot water was 106.4 degrees Fahrenheit. The LPA observed adequate lighting, furniture, and bedding in all of the rooms for the comfort and safety of the residents. LPA observed 7 days of nonperishable and 2 days of perishable foods on hand. Sharps and dangerous items were inaccessible to residents. Fire extinguisher was observed to be fully charged and last replaced on 9/22/2023.

The LPA reviewed the records of 5 residents and 1 staff member. The LPA interviewed 2 residents.

3 Type-B citations issued (refer to LIC809-D for details).

By 1/3/2024, Licensee will send updated forms to LPA:
· LIC308 - Designation of Facility Responsibility
· Evidence of Liability Insurance

Required Annual Inspection incomplete. LPA shall return unannounced to complete the inspection at a later date and time.

Exit interview conducted with Caregiver Marie Regacho. A copy of this report provided via email to Licensee/Administrator (ADM) Arsenia "Zeny" Lising.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 12/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2023
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 3


Document Has Been Signed on 12/22/2023 04:23 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 II
FACILITY NUMBER: 075601215

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.

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 staff records reviewed that no new staff or dementia training with staff has been completed, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2024
Plan of Correction
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Licensee shall complete the new staff and dementia training for all staff and send proof of training to LPA on or before due date.

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: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 12/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 12/22/2023 04:23 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 II
FACILITY NUMBER: 075601215

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87618(b)(3)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements:

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 of the residents using oxygen, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/29/2023
Plan of Correction
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Licensee shall post oxygen warning signs and inform Fire Department in writing of the use of oxygen at the facility.
Type B
Section Cited
CCR
87303(a)
87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times.

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 the loose seat cover in the bathroom toilet, gates outside not self-closing, door to garage with broken hinges, and sliding glass door that sticks all require repairs to be working correctly, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2024
Plan of Correction
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Licensee shall send picture proof of repairs on or before due date.
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: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 12/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3