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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200465
Report Date: 02/21/2025
Date Signed: 02/21/2025 11:03:57 AM

Document Has Been Signed on 02/21/2025 11:03 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:PARADISE MANORFACILITY NUMBER:
435200465
ADMINISTRATOR/
DIRECTOR:		MIGUEL, LYNDAFACILITY TYPE:
740
ADDRESS:1645 PEACHWOOD DRIVETELEPHONE:
(408) 729-1539
CITY:SAN JOSESTATE: CAZIP CODE:
95132
CAPACITY: 6CENSUS: 4DATE:
02/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Melanie Gavina Designated AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Marcela Yanez conducted an unannounced Required 1 Year visit and met with Melanie Gavina Designated Administrator.

During visit, LPA toured the facility inside and out. LPA toured the garage area and observed food storage areas and locked cabinets for cleaning supplies. LPA observed the kitchen area and observed locked cabinets for medications, sharp objects, and cleaning supplies. LPA observed perishable food supply of at least two days and a non-perishable food supply of at least seven days. Refrigerator temperature measured at 20 degrees F and freezer measured at -7 degrees F

LPA toured four resident bedrooms. Each bedroom had available bedding and clothing storage areas as well as functioning lights. While touring resident bedroom R1 LPA observed medication belonging to R1 accessible to residents in care. R1 is not allowed to administer their own medication. Medication was removed and placed in locked cabinet.

LPA toured 3 resident bathrooms. Each bathroom had available soap and paper towels and functioning lights. The water temperatures in the bathroom sinks measured with thermometer at 109 degrees F.

LPA toured the outside area and found the exits to be clear of obstructions. LPA observed fire extinguisher was last serviced on 04/25/24. LPA reviewed Fire and Earthquake log was last disaster drill was last conducted on 01/04/25 and 01/05/25.
LPA reviewed resident records for 2 resident. LPA reviewed 2 staff records and found them to be complete.

ADM tested the smoke detectors in the hallway smoke detector to function properly when tested.

Deficiencies were cited as per California Code of Regulations Title 22. This report was reviewed with Melanie Gavina Designated Administrator and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2025
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 02/21/2025 11:03 AM - It Cannot Be Edited


Created By: Marcela Yanez On 02/21/2025 at 10:44 AM
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: 02/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by having R1's medication not centally stored and in residents bedroom R1 is not allowed to adminster own medication which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/22/2025
Plan of Correction
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ADM will provide a letter of understanding of the regulation and provide to LPA by POC date 02/22/25.
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:Marcela Yanez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2025


LIC809 (FAS) - (06/04)
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