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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602869
Report Date: 09/21/2021
Date Signed: 09/21/2021 04:54:02 PM

Document Has Been Signed on 09/21/2021 04:54 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: 89DATE:
09/21/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Resident Services Director, Katrina EsguerraTIME COMPLETED:
02:05 PM
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Licensing Program Analyst (LPA) Marisela Garcia-Centeno made a Case Management visit to follow-up on a resident's death. LPA was granted entry into the facility by Receptionist, Carlene Basallo. LPA spoke with Resident Services Director, Katrina Esguerra, to whom she disclosed the purpose of the visit.

A Incident Report was received by Community Care Licensing (CCL) on September 18, 2021, informing that Resident #1 (R1) [staff was provided an LIC 811 that identifies the client] passed away at Resident's private home on September 13, 2021. According to information provided to CCL, R1's responsible party informed the Administrator of R1's death on September 13, 2021.

During today's visit, LPA reviewed and obtained copies of R1 and facility records and conducted a staff interview. No deficiencies were cited during today’s visit.

The Licensee was provided a copy of the appeal rights (LIC9058 01/16). An exit interview was conducted, and a copy of this report was emailed to Resident Services Director, Katrina Esguerra with an electronic read receipt as confirmation of receipt of documents.
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2021
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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