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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700691
Report Date: 01/04/2024
Date Signed: 01/04/2024 03:21:18 PM

Document Has Been Signed on 01/04/2024 03:21 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:PADUA CARE HOMEFACILITY NUMBER:
342700691
ADMINISTRATOR:DAYOAN, ANGELITAFACILITY TYPE:
740
ADDRESS:8708 THETFORD COURTTELEPHONE:
(916) 218-8556
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 6DATE:
01/04/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Angelita Dayoan, AdministratorTIME COMPLETED:
03:30 PM
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On 1/4/2024, at 2pm, Licensing Program Analyst (LPA) Arvin Villanueva arrived at this facility to conducted an unannounced Case Management-Annual continuation visit to continue with the Annual visit initiated on 12/27/2023. The LPA initially met with a staff on duty and explained the purpose of today's visit. Facility administrator was made aware of the visit and arrived to the facility shortly after. During this visit there are 6 residents in care with 2 staff on duty.

During this visit, LPA Villanueva completed a facility observation. Residents in care are in their bedrooms. LPA observed some residents have visitors. From previous visit on 12/27/2023, LPA Villanueva observed, based on resident file review, that 1 of 6 resident in care is diagnosed as bedridden and on hospice. LPA observed that this resident was in bedroom not cleared for bedridden. LPA also noted from the facility license that the facility has a bedridden clearance for one of the bedrooms (refer to the facility sketch). Based on interview with the administrator, the administrator planned to talk with the resident and their family or responsible person(s) if the resident in the bedridden bedroom can switch with resident in a non-bedridden bedroom. During today's facility observation, LPA Villanueva observed that the bedridden resident is in the appropriate bedroom cleared for bedridden resident. Per interview with the administrator, the residents and their families or responsible person(s) were okay with the bedroom switch. Also in today's visit, LPA completed and concluded staff interviews and resident interviews. LPA also concluded and completed the CARE Tools.

Per California Code of Regulations (CCR), Title 22, no deficiencies were observed. An exit interview was held, and a copy of the report was given.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 01/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/04/2024
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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