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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002535
Report Date: 08/17/2022
Date Signed: 08/17/2022 12:39:53 PM

Document Has Been Signed on 08/17/2022 12:39 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, 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:
08/17/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:38 AM
MET WITH:Noemi Figueroa, Licensee/AdministratorTIME COMPLETED:
12:50 PM
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A case management was conducted on this date in conjunction with a complaint 10 day visit for complaint control #22-AS-20220812173125. The purpose of this case management is to discuss the following deficiency that is being cited on this date.
While reviewing records for Resident 1 (R1), (R1)has a physician report dated 10/18/2021 and has an ambulatory status of Bedridden.

Licensing Program Analyst (LPA) LPA Rosie Quiroz met with Licensee/Adminsitrator (L/AD) Noemi Figueroa and discussed areas cited today and provided (L/AD) Figueroa with a copy of the fire clearance that does not reflect the approval for bedridden. In addition LPA explained to (L/AD) Figueroa the process of requesting a new fire inspection in order to accept and retain bedridden residents in the future.

Based on a review of the facility file and a review of the approved fire clearance, the facility is licensed for 6 Non Ambulatory residents and has a hospice waiver for four (4) residents, no rooms are designated for bedridden per fire inspection.

R1 was admitted to facility on 9/01/16 per admission agreement. Based on review of R1 Physician Report dated 10/8/2021, it is documented by physician that R1 is bedridden. The facility does not have approved fire clearance to provide care to resident that is bedridden. This potentially poses immediate danger to resident in care.

Per Health and Safety Code Section 1569.72(f)(a):Facility retaining a bedridden resident shall, within 48 hours of R1, diagnosis of bedridden the facility shall notify the local fire authority with jurisdiction in the bedridden resident's location of the estimated length of time the resident will retain his or her bedridden status in the facility. CONTINUED ON NEXT LIC 809 C PAGE...
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2022
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 08/17/2022 12:39 PM - It Cannot Be Edited


Created By: Rosie Quiroz On 08/17/2022 at 12:10 PM
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: 08/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/18/2022
Section Cited
CCR
1569.72(a)(f)

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Residents requiring skilled nursing or intermediate care; bedridden residents 1569.72(a)(f):(a) Except as otherwise provided...no resident shall be admitted or retained in a residential care facility for the elderly...Facility retaining a bedridden resident shall, within 48 hours of...CONTINUED BELOW
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(L/AD) Figueroa will report bedridden status to Fire Dept and CCL. (L/AD) will call and inform R1's responsible party to relocate resident by 8/18/2022.
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R1diagnosis of bedridden the facility shall notify the local fire authority with jurisdiction in the bedridden resident's location of the estimated length of time the resident will retain his or her bedridden status in the facility. CONTINUED...
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This requirement was not met as evidenced by: (L/AD) Figueroa failed to infrom CCL and local fire department of R1s bedridden status based on Physician report dated 10/18/21. This was verified with (L/AD) Figueroa

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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:Alisa Ortiz
LICENSING EVALUATOR NAME:Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2022


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 306002535
VISIT DATE: 08/17/2022
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CONTINUED...

Facility failed to notify local fire authority or CCL of R1 becoming bedridden and requiring total care, therefore the facility is being cited per Title 22, Division 6. (SEE LIC 809-D)

An exit interview was conducted with (L/AD) Noemi Figueroa and a copy of this report, LIC 809-D, and LIC 811 -Confidential Names and Appeal Rights were provided to (L/AD) Figueroa were provided at exit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022
LIC809 (FAS) - (06/04)
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