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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002535
Report Date: 01/27/2025
Date Signed: 01/27/2025 05:49:47 PM

Document Has Been Signed on 01/27/2025 05:49 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:PARADISE RESIDENTIAL HOMEFACILITY NUMBER:
306002535
ADMINISTRATOR/
DIRECTOR:		NOEMI FIGUEROAFACILITY TYPE:
740
ADDRESS:546 N. WRIGHTWOOD DRIVETELEPHONE:
(714) 516-2750
CITY:ORANGESTATE: CAZIP CODE:
92869
CAPACITY: 6CENSUS: 4DATE:
01/27/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:55 PM
MET WITH:Noemi Figueroa- AdministratorTIME VISIT/
INSPECTION COMPLETED:
06:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Nancy Guillen made an unannounced visit for the purpose of conducting a required annual Inspection. LPA was greeted and granted entry by Administrator (AD) Noemi A Figueroa after explaining the purpose of the visit. LPA observed the Administrator Certificate is current and expires on December 19,2026. This is a Residential Care Facility for the Elderly (RCFE) licensed to six non-ambulatory residents, with a hospice waiver for four. The facility is a two-story home with three resident bedrooms, two staff bedrooms, two resident bathrooms, one staff bathroom, a living room, a dining room, an activity room, a kitchen and an attached garage.

During the inspection, LPA and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, and observed the following:

LPA observed residents watching television in the living room and resting in their respective bedrooms. LPA observed four residents in care and three staff present. LPA observed the See Something Say Something Poster (PUB 475) mounted on the wall in the living room. All resident bedrooms had the required furnishings. LPA observed all resident beds had linens and blankets with additional linens stored in the hallway closet. LPA observed bathrooms were clean and equipped with grab bars and non skid floor mats. LPA observed all windows were appropriately screened. Bathroom was observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested at 116.4 and 119.3 degrees Fahrenheit. LPA toured the outside of the facility and observed outdoor passageways were free of obstruction and hazards. LPA observed the backyard had a shaded sitting area with furniture for resident use.

Continued on LIC 809

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Nancy Guillen
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2025
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 01/27/2025 05:49 PM - It Cannot Be Edited


Created By: Nancy Guillen On 01/27/2025 at 05:07 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: 01/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on staff file review, the licensee did not comply with the section cited above in one out of three staff records, which poses an immediate health and safety risk to persons in care. A health screening report and negative TB test was unable to be provided.
POC Due Date: 01/28/2025
Plan of Correction
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Administrator to provide Health Screening for staff and proof of negative TB test.
Type A
Section Cited
CCR
87465(h)(1)(C)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances: (C) Because of potential dangers related to the medication itself, or due to physical arrangements in the facility and the condition or the habits of other persons in the facility, the medications are determined by either a physician, the administrator, or Department to be a safety hazard to others.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on medication review, the licensee did not comply with the section cited above in two out of four resident's medications which poses an immediate health, safety and personal rights risk to persons in care. Resident's were taking medication without a doctor's order.
POC Due Date: 01/28/2025
Plan of Correction
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Administrator immediately removed medication for Resident #3 (R3) ,but will provide a doctor's prescription for Resident #2 (R2) for Acetaminophen and Loperamide to LPA by POC 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:Armando J Lucero
LICENSING EVALUATOR NAME:Nancy Guillen
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/27/2025 05:49 PM - It Cannot Be Edited


Created By: Nancy Guillen On 01/27/2025 at 05:07 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: 01/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and Administrator interview, the licensee did not comply with the section cited above due to not conducting quarterly disaster drills, which poses a safety rights risk to persons in care.
POC Due Date: 02/03/2025
Plan of Correction
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Administrator(AD) to conduct a quarterly drill and send proof to LPA by POC date. AD to continue to conduct disaster drills quarterly.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Armando J Lucero
LICENSING EVALUATOR NAME:Nancy Guillen
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2025


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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: PARADISE RESIDENTIAL HOME
FACILITY NUMBER: 306002535
VISIT DATE: 01/27/2025
NARRATIVE
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LPA observed the facility had a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke and carbon monoxide detectors tested operational. Two fire extinguishers were observed to be fully charged and located in the kitchen and activity room with a service date of September 20, 2024. Gas stove, microwave, washer, and dryer were all inspected and observed to be operable. The garage is used for storage and is kept locked and inaccessible to residents. Toxic chemicals, cleaning solutions, and disinfectants were observed to be locked and inaccessible to residents under the kitchen sink, garage and an outdoor storage. LPA observed knives were stored and locked in a kitchen drawer. LPA observed the First Aid Kit had all the required components. Upon record review, LPA observed Disaster Drills are not conducted quarterly; a deficiency was cited on today’s date.

During medication review, medication was observed to be centrally stored in a safe locked hallway closet located next to the kitchen. LPA reviewed medication and observed medication was labeled and stored inaccessible to residents in care, however medication for two out of four residents did not have a doctor’s order; a deficiency was cited on today’s date.

LPA reviewed four resident files. All the required documentation were present and current in the residents’ files reviewed. LPA reviewed three employee records. LPA observed records reviewed have a current First Aid certificate. All employee’s present have a criminal record clearance and were associated to the facility. One out of three staff were observed missing a health screening report and proof of a negative TB test; a deficiency was cited on today’s date.



Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights was left at the facility.


This report was reviewed with the Administrator and a copy of this report was provided to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Nancy Guillen
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025
LIC809 (FAS) - (06/04)
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