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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602869
Report Date: 08/16/2021
Date Signed: 08/16/2021 04:35:27 PM

Document Has Been Signed on 08/16/2021 04:35 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:CEDARS @ PARADISE VILLAGEFACILITY NUMBER:
374602869
ADMINISTRATOR:NITHI NARASAPPAFACILITY TYPE:
740
ADDRESS:2740 E 4TH STREETTELEPHONE:
(619) 475-5040
CITY:NATIONAL CITYSTATE: CAZIP CODE:
91950
CAPACITY: 150CENSUS: 92DATE:
08/16/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Administrator, Nithi NarasappaTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced Case Management Visit. LPA met with Administrator, Nithi Narasappa, and discussed the purpose of the visit. All staff that interacted with LPA had a current criminal record clearance.

Today's visit is in response to the self-reported incident regarding Resident 1 (R1 - see LIC811 Confidential Names List), that was submitted to the Regional Office on August 11, 2021.

LPA conducted a health and safety check at the facility, and no health or safety issues were identified. All staff present that interacted with the LPA have a current criminal record clearance. Residents observed appeared appropriate for the facility. Facility records were obtained on this date.

No deficiencies were cited or observed on this date.

An exit interview was conducted and a copy of their appeal rights (LIC9058 01/16) along with a copy of this report was provided to Administrator, Narasappa via electronic mail. An electronic read receipt confirmation was requested to be sent by the Administrator upon receipt of the documents.
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2021
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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