486800368-4-16-2026-21-AS-SSTN-DT7T72-20260416142802

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486800368
Report Date: 04/16/2026
Date Signed: 04/16/2026 02:28:09 PM

Document Has Been Signed on 04/16/2026 02:28 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	PARADISE VALLEY ESTATES		FACILITY NUMBER:	486800368
ADMINISTRATOR/ DIRECTOR:	STACK, SHANNON		FACILITY TYPE:	741
ADDRESS:	2600 ESTATES DRIVE		TELEPHONE:	(707) 432-1100
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94533
CAPACITY: 743		CENSUS: 498	DATE:	04/16/2026
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:00 PM
MET WITH:	Phyllicia Xiong, LVN -Assisted Living Manager		TIME VISIT/ INSPECTION 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	At approximately 1:00 PM Licensing Program Analyst (LPA) Star Stevenson arrived unannounced on a case management visit regarding a self-reported Unusual Incident Report (LIC624) received by the Department on 04/10/2026 in which a resident (R1) was able to open a memory care window in their room on the night of 04/09/2026 and place their walking device over an approximately 12" high by 15" wide concrete ledge and exit the building where they were later found by the security staff at the facilities guard shack inside the perimeter of Paradise Valley Estates. LPA notes that immediate notifications were made to R1’s Primary Care Physician (PCP), who was asked to evaluate R1 for consideration of medication changes related to sundowning and exit seeking behaviors. In addition, the spouse of R1 was immediately notified, with spouse of R1 noted to agree to the request of R1’s PCP to potentially adjust behavior medicines for R1. LPA obtained documents, made observations and conducted interviews around the inner-facility elopement of R1. It was revealed through the Physician Assessment (LIC602) and care note review that R1 can be “confused”, has known “wandering behavior” and “sundowning behavior”, requires “constant supervision” and is able to “ambulate without assistance”. It was also revealed through interview of S1 that R1 exited from their private apartment where they can be alone and it was from this apartment that R1 was able to push in a locking clamp of their ground level window and exit their apartment without staff initially knowing. Continued on LIC809C

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/16/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: PARADISE VALLEY ESTATES	FACILITY NUMBER: 486800368
	VISIT DATE: 04/16/2026

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Continued for LIC809
Review of documents and interviews obtained during today's case management visit indicate staff moved quickly to remedy this potential danger for memory care residents and by the next morning Management and Communication/IT staff had placed an order for window alert alarms for all Memory Care resident room windows. In addition, interview with S1 revealed that a motion room sensor was placed in R1's room the night of the inner-facility elopement. (see photos of window sensor and room motion alarm)

No deficiencies are cited.

Report was reviewed with Assisted Living Manager whose signature here denotes receipt.

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/16/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2026

LIC809 (FAS) - (06/04)

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