374604829-9-28-2026-08-AS-ABOS-DYCRND-20260928131010

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604829
Report Date: 09/28/2026
Date Signed: 09/28/2026 01:10:37 PM

Document Has Been Signed on 09/28/2026 01:10 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	PARADISE SENIORS LIVING VALLEY		FACILITY NUMBER:	374604829
ADMINISTRATOR/ DIRECTOR:	CARDONA, BRENDA		FACILITY TYPE:	740
ADDRESS:	8117 JEFFERSON ST		TELEPHONE:	(619) 750-8488
CITY:	LEMON GROVE	STATE: CA	ZIP CODE:	91945
CAPACITY: 4		CENSUS: 2	DATE:	09/28/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Caregiver Eliza Cardona		TIME VISIT/ INSPECTION COMPLETED:	01:13 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 Analysts (LPAs) Angelica Boyles and Leticia Arroyo conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit with Caregiver Eliza Cardona. LPAs also spoke with licensee Brenda Cardona over the phone. According to the facility’s license, the facility is approved for residents age range 60 and over with a maximum capacity of 4, all of whom may be non-ambulatory. The facility has an approved hospice waiver for 2. LPAs, accompanied by caregiver, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was comfortable and complaint. Hot water temperatures at taps accessible to residents were all compliant. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to residents. Medications were labeled, as required, and stored in locked areas. LPAs audited medications and found medication which was to be discarded on 9/18/26. (CONTINUED ON LIC 809C)

Simon Jacob
Angelica Boyles
	DATE: 09/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2026

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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: PARADISE SENIORS LIVING VALLEY	FACILITY NUMBER: 374604829
	VISIT DATE: 09/28/2026

NARRATIVE

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(CONTINUED FROM LIC 809)

No pools or bodies of water were observed on the premises. Per the caregiver, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPAs reviewed multiple staff and resident records/files. The reviewed files did not contain required documents. Resident #1 (R1) and Resident #2 (R2) did not have updated record of their Centrally Stored Medication and Destruction Record. Additionally, R2's Physician's Report was not signed by a physician. Staff #1 (S1) did not have an updated first aid training certificate. Staff #2 (S2) did not have record of annual required training. Confidential records were stored in locked areas.

Five deficiencies were observed and being cited during today's annual inspection per California Code of Regulations, Title 22 (refer to the attached LIC 809 D pages). A plan of correction was jointly developed with facility staff. An exit interview was conducted with caregiver Eliza Cardona, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit.

NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Angelica Boyles
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/28/2026 01:10 PM - It Cannot Be Edited

Created By: Angelica Boyles On 09/28/2026 at 12:21 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: PARADISE SENIORS LIVING VALLEY	FACILITY NUMBER: 374604829
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(c)(1)

Medical Assessment

(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review, the licensee did not comply with the section cited above in 1 out of 1 resdient did not have the LIC602 signed by a physician which pose a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/16/2026
	Plan of Correction
1 2 3 4	Facility staff will have the LIC602 signed by a physician and submit the updated form to LPA by POC due date.

Type B

Section Cited

CCR

87411(c)(1)

(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training...(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records reviewed, the licensee did not comply with the section cited above in S1 did not have updated first aid training which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/16/2026
	Plan of Correction
1 2 3 4	S1 will renew first aid training and submit documentation to LPA by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:

	Angelica Boyles
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/28/2026 01:10 PM - It Cannot Be Edited

Created By: Angelica Boyles On 09/28/2026 at 12:28 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: PARADISE SENIORS LIVING VALLEY	FACILITY NUMBER: 374604829
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87506(b)(14)

(b) Each resident’s record shall contain...the following information: (14) Current centrally stored medications... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records reviewed, the licensee did not comply with the section cited above in 2 out of 2 residents did not have updated LIC622 Centrally Stored Medication and Destruction Record which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/16/2026
	Plan of Correction
1 2 3 4	Facility staff will complete an updated LIC622 for R1 and R2 and submit to LPA by POC due date.

Type B

Section Cited

CCR

87465(i)

(i) Prescription medications which are…to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident… This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observation, the licensee did not comply with the section cited above in that there was medication being centrally stored that was to be discarded on 9/18/26 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/16/2026
	Plan of Correction
1 2 3 4	Facility staff will properly destroy and/or discard medication and will provide LPA with record of destruction/discarding it by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:

	Angelica Boyles
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/28/2026 01:10 PM - It Cannot Be Edited

Created By: Angelica Boyles On 09/28/2026 at 12:42 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: PARADISE SENIORS LIVING VALLEY	FACILITY NUMBER: 374604829
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(c)(3)(B)

(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training...(3) The training shall include, but not be limited to, the following: (B) Importance and techniques of personal care services, including but not limited to, bathing, grooming, dressing, feeding, toileting, and infection control... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records reviewed, the licensee did not comply with the section cited above in S2 did not have record of required annual training which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/16/2026
	Plan of Correction
1 2 3 4	S2 will complete required annual training. Proof of training will be submitted to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:

	Angelica Boyles
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2026

LIC809 (FAS) - (06/04)

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