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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002535
Report Date: 07/01/2021
Date Signed: 07/01/2021 09:27:41 AM

Document Has Been Signed on 07/01/2021 09:27 AM - 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:PARADISE RESIDENTIAL HOMEFACILITY NUMBER:
306002535
ADMINISTRATOR:NOEMI FIGUEROAFACILITY TYPE:
740
ADDRESS:546 N. WRIGHTWOOD DRIVETELEPHONE:
(714) 516-2750
CITY:ORANGESTATE: CAZIP CODE:
92869
CAPACITY: 6CENSUS: 6DATE:
07/01/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Yulisa FogueroaTIME COMPLETED:
09:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Ruth Martinez made an unannounced Case Management visit to the facility today in conjunction with a complaint investigation. LPA arrived at facility and was greeted by Yulisa Figueroa, Assistant Administrator and was granted entry. LPA explained the nature if the visit.

This is to issue a citation today in conjunction with investigation to complaint number 22-AS-20210324133018. The Department observed additional deficiencies such as lack of Administrators knowledge of regulations as evidence by retention of a resident with prohibited health conditions. Administrator did not monitor R1’s change of condition, allowed an unqualified staff to treat unstageable wounds, and did not follow through with physician’s orders or obtain a higher level of care for R1.

Based on this inspection, there were deficiencies observed in the facility in areas evaluated and are noted on the attached LIC 809-D forms.



An exit interview was conducted and a copy of this report and appeals rights was provided to facility representative.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 07/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2021
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 07/01/2021 09:27 AM - It Cannot Be Edited


Created By: Ruth Martinez On 07/01/2021 at 08:40 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: PARADISE RESIDENTIAL HOME
FACILITY NUMBER: 306002535

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/02/2021
Section Cited
CCR
87405(d)(2)

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Administrator Qualifications and Duties: The administrator shall have the qualifications specified… Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement is not met as evidenced by; Administrator did not monitor R1’s change of condition, allowed an unqualified staff to treat unstageable
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Licensee Noemi Figueroa will develop and submit a plan on how she will conduct ongoing oversight of the facility operations ensuring that all applicable laws, rules and regulations are followed.
Licensee to submit to LPA by POC due date.
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wounds, and did not follow through with physician’s orders or obtain a higher level of care for R1. This poses an immediate Health and Safety Risk to residents 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:Marina Stanic
LICENSING EVALUATOR NAME:Ruth Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2021


LIC809 (FAS) - (06/04)
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