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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801837
Report Date: 01/21/2025
Date Signed: 01/21/2025 10:58:02 AM

Document Has Been Signed on 01/21/2025 10:58 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:PARADISE VALLEY RESIDENTIAL CARE HOMEFACILITY NUMBER:
486801837
ADMINISTRATOR/
DIRECTOR:		GADIA, EDWARDFACILITY TYPE:
740
ADDRESS:524 AMERICANO WAYTELEPHONE:
(707) 344-4744
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 6DATE:
01/21/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:54 AM
MET WITH:Licensee, Edward GadiaTIME VISIT/
INSPECTION COMPLETED:
11:10 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Cuadra and Magdaleno conducted a case management visit to cite deficiencies discovered during a complaint investigation and met with Licensee, Edward Gadia.

LPA learned through records review and interviews that on 10/4/2024 facility staff did not seek any medical attention from resident’s (R1) physician after staff (S1 & S2) were notified by an outside agency that R1 was complaining of pain and bruising was noted on their wrist. Per S1 and S2, they notified the Licensee about R1’s condition, but it was until 10/17/24 when an outside agency came to the facility who noticed bruising was not yellowing, then they contacted R1’s physician who referred them to have x-rays done and a diagnosis revealed an acute fracture distal ulna. According to facility progress notes, on 3/19/24 R1 initiated to experience aggressive behaviors towards the staff, and swing their arms at them, but it wasn’t timely addressed by facility staff. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to seek medical care resulted in violation causing injury to person in care $500 immediate civil penalty issued. The licensee was informed that additional civil penalties are under review by the Department per Health and Safety Code 1569.49 (f).
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2025
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 01/21/2025 10:58 AM - It Cannot Be Edited


Created By: Marisol Cuadra On 01/21/2025 at 10:04 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: PARADISE VALLEY RESIDENTIAL CARE HOME
FACILITY NUMBER: 486801837

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/22/2025
Section Cited
CCR
87465

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87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional & social functioning & that appropriate assistance is provided when such observation reveals unmet needs...& brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement has not been met as evidence by:
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Licensee to ensure resident’s physician and their responsible parties are always informed of any changes in resident’s condition and care needs. Licensee will develop a procedure that it will be attached to the facility plan of operation indicating how the facility will ensure that resident’s physician and their responsible parties will be informed of any changes in resident’s condition and care needs by POC due date. Failure to seek medical care resulted in violation causing injury to person in care $500 immediate civil penalty issued.
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Based on interviews and record review the licensee failed to update R1’s care plan and medical assessment addressing mental and behavioral changes noticed since 3/19/24. Also, the facility staff did not seek medical attention after observing R1’s bruising and complaints of pain, which poses an immediate risk to the health and safety of the residents in care.
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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:Bethany Moellers
LICENSING EVALUATOR NAME:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 01/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/21/2025


LIC809 (FAS) - (06/04)
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