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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700691
Report Date: 12/24/2024
Date Signed: 12/24/2024 01:33:00 PM

Document Has Been Signed on 12/24/2024 01:33 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/
DIRECTOR:		DAYOAN, ANGELITAFACILITY TYPE:
740
ADDRESS:8708 THETFORD COURTTELEPHONE:
(916) 218-8556
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 6DATE:
12/24/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Angelita DayoanTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Arvin Villanueva conducted an unannounced Case Management - Annual Continuation visit today at the facility to continue with the Annual visit initiated on 12/20/2024. LPA met with staff on duty and explained the purpose of the visit. The Administrator, Angelita Dayoan, was notified and arrived shortly after. Present during today's visit were 6 residents in care with 2 staff on duty.

The LPA continued with facility visit to ensure facility is in compliance with Title 22 Regulations. Facility is fire cleared for 6 non-ambulatory residents and one room, located near the front entrance of the facility was fire cleared for bedridden use.

Review of 3 resident files (R1, R2, R3) which include review of Admission Agreement, Physician Reports, Needs and Services Plan, Centrally Stored Medication Record and Ambulatory Status. During the record review, it was noted that a resident (R1) had been assessed by a physician (per LIC602 dated 7/17/24) as bedridden and was observed in a bedroom that had not been approved for bedridden use. A Technical Advisory on this issue had already been provided to the Licensee during the previous annual visit on 12/27/23.

Medication review of 3 residents (R1, R2, R3) include review of physician orders for over-the-counter medications. TA was provided to ensure resident physicians indicate residents' capacity to determine the need for PRN medication.

Review of 4 staff files (S1, S2, S3, S4) which include review of background clearance, First Aid/CPR certificate, Health Screen, Initial and Ongoing Training. No issues were noted at this time.

Facility conducts quarterly disaster drill and last drill was on 11/16/24. Facility has a dementia and infection control plan.

Administrator provided the following documents during this visit: current Liability Insurance Certificate, LIC 610E, LIC500 and LIC308 to the Department.

This facility is hereby cited per 22 CCR Sections 87202(a)(2). An immediate civil penalty in the amount of $500 is hereby assessed due to a violation of fire clearance.

Exit interview was conducted and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 12/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/24/2024
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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Document Has Been Signed on 12/24/2024 01:33 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 12/24/2024 at 01:18 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PADUA CARE HOME
FACILITY NUMBER: 342700691

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)(2)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, record review and interview, the licensee did not comply with the section cited above. R1 was assessed by their physician as bedridden but during this visit R1 was observed to be placed in a bedroom not cleared for bedridden use, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/26/2024
Plan of Correction
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Corrected during this visit: R1 was moved to a room cleared for bedridden use (Bedridden Room indicated on the facility sketch).
Per discussion, Administrator will submit a statement of understanding of the regulation as it relates to bedridden clearance and care of bedridden residents. POC to be submitted by the due date noted above.
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:Stephen Richardson
LICENSING EVALUATOR NAME:Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:
DATE: 12/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/24/2024


LIC809 (FAS) - (06/04)
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