<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003902
Report Date: 11/19/2024
Date Signed: 11/19/2024 12:06:09 PM

Document Has Been Signed on 11/19/2024 12:06 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:PARADISE QUALITY GUEST HOME IIFACILITY NUMBER:
347003902
ADMINISTRATOR/
DIRECTOR:		BEATRIZ L. AFALLAFACILITY TYPE:
740
ADDRESS:3432 PAGEANT DRIVETELEPHONE:
(916) 613-7405
CITY:SACRAMENTOSTATE: CAZIP CODE:
95826
CAPACITY: 6CENSUS: 5DATE:
11/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Beatriz AfallaTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPAs) Vincent Moleski and Holly Williams arrived unannounced to conduct an annual inspection. LPA Moleski met with facility administrator Beatriz Afalla and explained the purpose of the visit.

LPA Moleski reviewed five resident files (R1-R5) and three staff files (S1-S3). LPA Moleski observed that there was no LIC 602 present in R2's file. Afalla said it was misplaced.

LPA Moleski observed in R4's file an LIC 602 dated 12/28/24, which diagnosed R4 with a "pressure ulcer of sacral region & buttock, unstageable." LPA Moleski reviewed R4's discharge paperwork from a skilled nursing facility dated 12/31/23, which was prepared prior to R4's release to this facility. The discharge paperwork stated that R4 had pressure injuries on their left heel, sacrum, and left and right buttocks. Afalla said R4 has never been on hospice. Afalla said that the wounds have since healed.

LPA Moleski observed in R5's file an LIC 602 dated 11/2/23, which diagnosed R5 as bedridden. LPA Moleski observed that R5 is currently residing in room #3. This facility's fire clearance approves one bedridden resident only in room #1.

LPA Moleski toured the facility with Afalla and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 70 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 110 degrees Fahrenheit, which is within the required range of 105 and 120 degrees.

[continued on 809-C]
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 11/19/2024 12:06 PM - It Cannot Be Edited


Created By: Vincent Moleski On 11/19/2024 at 11:44 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PARADISE QUALITY GUEST HOME II
FACILITY NUMBER: 347003902

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87606(c)
Care of Bedridden Residents
(c) To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the terms of their fire clearance, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/21/2024
Plan of Correction
1
2
3
4
Licensee agrees to provide LPA Moleski a written plan of correction by POC due date.
vincent.moleski@dss.ca.gov
Type A
Section Cited
CCR
87615(a)(1)
Prohibited Health Conditions
(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure sores (dermal ulcers).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and interview, the licensee retained a resident with a prohibited health condition, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/20/2024
Plan of Correction
1
2
3
4
Licensee agrees to write a statement acknowledging the requirements as described above, and asserting that residents with prohibited health conditions will not be accepted or retained.
vincent.moleski@dss.ca.gov
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:Vincent Moleski
LICENSING EVALUATOR SIGNATURE:
DATE: 11/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 11/19/2024 12:06 PM - It Cannot Be Edited


Created By: Vincent Moleski On 11/19/2024 at 11:44 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PARADISE QUALITY GUEST HOME II
FACILITY NUMBER: 347003902

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not keep on file an LIC 602 for R2, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/10/2024
Plan of Correction
1
2
3
4
Licensee agrees to acquire a new LIC 602 for R2 by POC due date and to send a copy to LPA Moleski by POC due date.
vincent.moleski@dss.ca.gov
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Vincent Moleski
LICENSING EVALUATOR SIGNATURE:
DATE: 11/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: PARADISE QUALITY GUEST HOME II
FACILITY NUMBER: 347003902
VISIT DATE: 11/19/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA Moleski observed first aid supplies, a fully-charged and up-to-date fire extinguisher, and carbon monoxide/smoke detectors. LPA Moleski observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Moleski observed a locked closet for the storage of medication. LPA Moleski observed locked cabinets for the storage of cleaning solutions and knives.

LPA Moleski interviewed one staff member (S1) and LPA Williams interviewed one resident (R1).

This facility is hereby cited per 22 CCR Section 87606(c), 87615(a)(1), and 87458(a). An immediate civil penalty in the amount of $500 for a fire clearance violation is hereby assessed. An exit interview was held with Afalla. Appeal rights and a copy of this report were left with Afalla.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4