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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200465
Report Date: 02/15/2024
Date Signed: 02/15/2024 05:39:30 PM

Document Has Been Signed on 02/15/2024 05:39 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
CENTRAL COAST CR/RES, 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: 4DATE:
02/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Lead staff Melanie GavinaTIME COMPLETED:
05:45 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) Manuel Monter conducted an unannounced annual inspection visit, and met with Lead staff Melanie Gavina (S1). During the visit, LPA observed 4 residents and 2 staff. S1 called Administrator (ADM) Lynda Miguel and ADM stated S1 could give LPA tour and sign on her behalf.

LPA toured the facility inside out with S1 which included the Living room, kitchen, dining room, 4 restrooms and 4 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. There was no obstruction to block the walkways.

While touring resident bedroom #3, LPA observed 7 containers of dish washing detergent on the ground. While touring the bathroom #2, which is located across from bedroom #3, LPA observed a bottle of dish washing detergent. (Photographs were taken.)

Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F, and hot water temperature was measured at 118 degrees F in resident bathrooms.

Fire extinguisher was serviced in May 10, 2023. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by S1, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on January 7, 2024.

Page 1 out of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2024
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 3
Document Has Been Signed on 02/15/2024 05:39 PM - It Cannot Be Edited


Created By: Manuel Monter On 02/15/2024 at 05:06 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: 02/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. LPA observed 7 containers of dish washing detergent on the ground. While touring the bathroom #2, which is located across from bedroom #3, LPA observed a bottle of dish washing detergent below the sink. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/22/2024
Plan of Correction
1
2
3
4
ADM stated she will send written plan of action on how the facility will ensure Disinfectants, cleaning solutions, poisons, and other items which could pose a danger if readily available to residents shall be stored where inaccessible to residents. ADM stated she will send written plan of action by POC date, 2/22/2024.
Type B
Section Cited
CCR
87455(b)(7)
(7) Persons who are under 60 years of age whose needs are compatible with other residents in care, if they require the same amount of care and supervision as do the other residents in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in. Residents R1, R2 and R3 are under the age of 60. The facility has a census of 4 and the facility did not request an exception request for the residents who are under the age of 60 years. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/22/2024
Plan of Correction
1
2
3
4
ADM stated she will send exception requests for the residents who are under the age of 60. ADM stated she will also send a written letter of understanding regarding the regulation. ADM stated she will send her plan of corrections by POC date, 2/22/2024.
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:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: PARADISE MANOR
FACILITY NUMBER: 435200465
VISIT DATE: 02/15/2024
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
26
27
28
29
30
31
32
LPA reviewed facility records for 2 staff and 2 residents. While reviewing resident records, LPA discovered that residents R1, R2 and R3 are under the age of 60. LPA reviewed 2 resident medications and centrally stored medication records. LPA reviewed 2 residents P&I records. LPA conducted interviews with 2 staff (S1 to S2) and 2 residents (R1-R2).

Deficiencies are being cited during today's visit, see LIC809-D. This report was reviewed with Lead staff Melanie Gavina and a copy of the signed report was provided.

Page 2 out of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3