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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200465
Report Date: 05/31/2023
Date Signed: 06/01/2023 08:01:45 AM

Document Has Been Signed on 06/01/2023 08:01 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, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
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:
05/31/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Melanie GavinaTIME COMPLETED:
04:35 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Assist Administrator (AADM) Melanie Gavina. Staff Nercisa Cabrera (S1) and Evelyn Bergunia (S2) and 5 residents (R1 - R6) were observed in the facility.

LPA checked 5 resident files and 3 staff files.

LPA toured the facility inside out with ADM. Living room, family room, kitchen, dinning room and 4 restrooms were inspected. 2 shared resident bedrooms, 2 single resident rooms, and laundry area were inspected. One staff live-in room was observed in facility. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication closet, and knives closet and cleaning product closet were observed locked. Room temperature was at 72 degree F, and hot water temperature was at 116 degree F in facility. Fire extinguisher was serviced on 5/10/2023. The temperature of freezer was observed at 0 degree F. The temperature of refrigerator was observed at 30 degree F. One of the screen of the bed room was broken.

The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors and carbon monoxide detectors were tested by ADM, and they were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways.

Deficiency was found. LIC809-D and Appeal Rights were attached. Exit interview was conducted with AADM. This report was provided to AADM for signature. A copy of the report was provided to AADM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2023
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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Document Has Been Signed on 06/01/2023 08:01 AM - It Cannot Be Edited


Created By: Chihhsien Chang On 05/31/2023 at 04:22 PM
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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: PARADISE MANOR
FACILITY NUMBER: 435200465

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(c)
87303 Maintenance and Operation (c) All window screens shall be clean and maintained in good repair.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, one of the window screens was not in good repair, the licensee did not comply with the section cited above, which poses/posed a potential health risk to persons in care.
POC Due Date: 06/07/2023
Plan of Correction
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Assist Administrator agreed to submit a Plan of Correction by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Romeo Manzano
LICENSING EVALUATOR NAME:Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2023


LIC809 (FAS) - (06/04)
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