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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602382
Report Date: 11/16/2021
Date Signed: 11/17/2021 09:35:59 AM

Document Has Been Signed on 11/17/2021 09:35 AM - 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:PARADISE HOME CAREFACILITY NUMBER:
374602382
ADMINISTRATOR:INOCENCIO, REMEDIOSFACILITY TYPE:
740
ADDRESS:4478 SAN JOAQUIN STREETTELEPHONE:
(760) 754-2774
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY: 6CENSUS: 5DATE:
11/16/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:54 PM
MET WITH:Administrator, Remedios InocencioTIME COMPLETED:
04:04 PM
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Licensing Program Analyst (LPA), Kristina Ryan, conducted an unannounced case management visit to follow up on an incident report received on November 12, 2021. LPA Ryan introduced herself, stated the purpose of the visit, was allowed entry and met with Administrator, Remedios Incencio.

Community Care Licensing (CCL) received an incident report on November 12, 2021 regarding a resident being hospitalized.

During today's visit, LPA toured the facility, reviewed resident records, and interviewed staff and residents. No deficiencies were cited.

An exit interview was conducted with Remedios Incencio. A copy of this report, along with the Licensee Rights (9058 01/16) was emailed to the administrator at the conclusion of the visit, an electronic response confirms the receipt of these documents.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Kristina Ryan
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2021
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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