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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200465
Report Date: 02/18/2022
Date Signed: 02/18/2022 03:26:43 PM

Document Has Been Signed on 02/18/2022 03:26 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,
, CA
FACILITY NAME:PARADISE MANORFACILITY NUMBER:
435200465
ADMINISTRATOR:MIGUEL, LYNDAFACILITY TYPE:
740
ADDRESS:1645 PEACHWOOD DRIVETELEPHONE:
(408) 729-1539
CITY:SAN JOSESTATE: CAZIP CODE:
95132
CAPACITY: 6CENSUS: 6DATE:
02/18/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Melanie GavinaTIME COMPLETED:
02:35 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 Analyst (LPA) Marybeth Donovan conducted a Technical Assist (TA) Visit via Zoom platform with Melanie Gavina Facility Staff, Lori Kopplinger RN, Program Clinical Consultant, and Sarah Yip Licensing Program Manager to provide technical assistance to prevent and mitigate the spread of COVID 19 in the facility. LPA conducted a virtual tour of the facility.

During today's TA-Visit, recommendations were discussed as follows:

1. Use updated list of COVID 19 Symptoms for Screening for visitors and staff
2. Use paper towels instead of cloth towels
3. Use foot operated waste receptacles in the kitchen, bathrooms and isolation room
4. Place PPE supplies in closed container next to Isolation Room
5. Enter isolation from inside the home and exit through the exterior door with contaminated PPEs.
6 Review OSHA N95 Fit Test Requirements for staff working with COVID 19 Positive residents
7. Use disinfectants with 2 minutes or less wet time

LPA will forward updated COVID Symptom List, Screening Questionnaire, PPE Donning and Doffing Posters and Provider Information PIN 22-07-ASC Dated 2/8/2022 to include Visitation Guidelines.

Report reviewed with Melanie Gavina and a copy emailed for signature.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Marybeth Donovan
LICENSING EVALUATOR SIGNATURE: DATE: 02/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/18/2022
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 1