Paradise Gardens

Type of visit: Required - 1 Year

On June 2, 2026 Licensing Program Analysts (LPA) B. Miranda & A. Porter arrived at the facility unannounced to conduct an annual inspection. LPA attempted to contact Administrator Margaret Gardea but was unsuccessful. LPA left a voicemail requesting a call back. LPAs met with caregiver Anna Perez LPAs was not able to review staff or resident files during the visit. Water temperature in the kitchen read at 124.8 degrees Fahrenheit and 128.1 degrees Fahrenheit in a common bathroom. LPAs observed the following: Food not being properly stored/labeled Expired sandwich meat in the refrigerator Medication cabinet to be unlocked and accessible to residents in care Hygiene products accessible throughout the facility Exit door to backyard did not have an audio alarm Door leading into garage from inside did not have an audio alarm Outside table had a lighter Fire Extinguisher did not have purchase or service date Carbon monoxide detector was tested and in working order Currently the facility has 3 residents on hospice Due to staff not having access to files LPAs were not able to review the documents needed for the annual inspection. Follow-up visit is warrant for a later date to complete annual inspection. Citations will be issued during follow-up visit. Exit interview was conducted and a copy of this report LIC809 was provided Anna Perez- Caregiver.the state’s words, verbatim · CDSS document, Jun 2, 2026

Type of visit: Office

On 08/5/2025, an informal office visit was held at the Fresno Regional Office. The purpose of the informal meeting was to discuss recently identified issues/concerns associated with the operation of the facility. The informal meeting process was explained during this meeting. The following were in attendance at this meeting: License, Linda Boden BY PHONE Administrator, Margaret Gardea Direct Care Staff, Alfredo Benavides Licensing Program Manager I, Sergiy Pidgirny Licensing Program Manager I, Alexandria Walton Licensing Program Analyst, Daiquiri Boyd Licensing Program Analyst, Melinda Medina (continued on next page) During this meeting the following topics were discussed: - Incident reporting - Staffing Concerns - Administrator Qualifications - Client Records - Food Service - Buildings and Grounds - Fingerprint Clearance - Accountability of licensee as a governing body Licensee and Administrator stated: Licensee stated that she was willing to assist the Administrator as much as she is able by phone, during this meeting. In addition, on 06/30/2025 during an annual inspection at Paradise Gardens, it was noted that the Administrator reported not having sufficient time to complete administrative duties due to performing caregiving duties. As a result, the facility has not been in compliance in multiple areas including resident and personnel records, buildings and grounds, insufficient staffing, and absent hospice care plans. During this meeting, deficiencies are being cited in accordance with California Code of Regulations, Title 22, Division 6 on the attached 809D. The Licensee and Administrator were informed that continued non-compliance may necessitate the Department to seek Administrative Actions. The Licensee and Administrator were notified that the hospice wavier for the facility has been reduced to two (2) residents due to non-compliance. Exit interview conducted. Plan of Correction was developed and reviewed. A copy of this report and appeal rights were discussed and provided to the Administrator during this meeting.the state’s words, verbatim · CDSS document, Aug 5, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Aug 12, 2025

All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility…This requirement was not met as evidenced by: Based on observations and interviews, the Licensee did not comply with section 87405(a) when the Administrator was unable to complete administrative duties due to performing caregiving duties… which is a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 5, 2025

Plan of correction: Administrator to provide a written statement that will detail the facilities plan that will ensure that section 87405(a) is met. Written statement to be provided to Licensing by 08/12/2025.

Type of visit: Case Management - Annual Continuation

On June 30, 2025 Licensing Program Analyst (LPA) Daiquiri Boyd visited the facility to continue the Annual Inspection. LPA was greeted by Margaret Benavideo, caregiver and Administrator. LPA completed the review of the CARE Tool for this facility inspection. LPA reviewed resident files and staff training files. Training files found deficient. LPA observed additional Building and Grounds issues in addition to the CARE Tool. Fingerprints were not on file for one of the individuals in the back yard residence. Fingerprint record clearance was not transferred for one staff. Citations issued on this day. LPA requests that updated copies of Liability Insurance, LIC9020 be sent to CCL by 7/14/2025.the state’s words, verbatim · CDSS document, Jun 30, 2025

The state marks this report as 24 pages; the online copy we transcribed has 10. You can request the full file from the county licensing office.

Type of visit: Case Management - Annual Continuation

On 06/05/2025, Licensing Program Analyst (LPA) Daiquiri Boyd arrived unannounced to conduct an annual inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. Facility staff contacted Administrator, Margaret Gardea-Benavidas (AD) via telephone. AD arrived a short time later. LPA conducted a tour inside and outside of facility. Facility observed to be odor free and at a comfortable temperature. Common areas were furnished well with adequate seating and lighting available. Resident rooms appeared clean and had required furnishings. LPA observed an adequate supply of linen. Hot water measured 118.4 degrees F. Kitchen toured, appeared clean, and safe for food preparation. Wall mounted Fire extinguisher purchased on 12/18/2023. "First Alert Kitchen Fire" extinguisher on kitchen counter purchased 12/2/2024. Last fire drill conducted on 05/20/2025. All cleaning supplies are locked and inaccessible. LPA reviewed staff and client records. Facility has a planned activity schedule on site. LPA was unable to complete this inspection on this day. LPA will return to complete inspection on another day. No citations were issued on this day. A copy of this report was discussed and provided to AD, whose signature on this form confirms receipt of this document.the state’s words, verbatim · CDSS document, Jun 5, 2025

Type of visit: Required - 1 Year

On 05/20/2025, Licensing Program Analyst (LPA) Daiquiri Boyd arrived unannounced to conduct an annual inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. Facility staff, Bobbie Arnold stated that Administrator, Margaret Gardea-Benavidas was not available and that she was in class until 2PM doing the Administrator Certification class. LPA asked if there was someone else that could assist with providing files and was authorized to sign at the end of the inspection. Staff stated that there was no one else and that they could call the "owner"(Licensee). Staff reported that Licensee was giving a tour at their other facility and wasn't answering her phone. LPA was unable to complete this inspection on this day due to a time conflict. LPA to return to complete this inspection on a later date. No staff with authorization were available to sign.the state’s words, verbatim · CDSS document, May 20, 2025

Allegation investigated: Staff don’t answer facility phone

On 11/19/2024, Licensing Program Analyst (LPA) Walton arrived unannounced to commence an complaint investigation. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA was granted entry to the facility by facility staff. Staff contacted Administrator, Margaret Gardea-Benavida, who arrived a short time later. LPA met with Administartor. During today's LPA conducted interviews and confirmed that the facility phone is operational. Staff interviews revealed that S1 was providing care to another resident in the home and was unable to answer the phone, caller did not leave a voicemail, and as a result S1 was unable to return the call once S1 completed duties. Based on interviews conducted with staff, the allegation: Staff don't answer facility phone is UNSUBSTANTATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficiencies issued. Exit interview conducted. A copy of this report was discussed and provided to Administrator, Margaret Gardea-Benavida, whose signature on this form confirms receipt of this document. Unsubstantiatedthe state’s words, verbatim · CDSS document, Nov 19, 2024 · control 24-AS-20241118121205

Type of visit: POC

On 07/29/2024, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct a POC visit. LPA introduced self, stated the purpose of the visit and was granted entry to the facility. LPA met with Administrator, Margaret Gardea-Benavidas. The purpose of today's visit is to clear deficiencies that were issued during the annual inspection on 06/18/2024. During today's visit, LPA conducted a facility tour and reviewed records. No deficiencies issued during today's inspection. Exit interview conducted. A copy of this report was discussed and provided to Administrator, Margaret Gardea-Benavidas, whose signature on this form confirms receipt of this document.the state’s words, verbatim · CDSS document, Jul 29, 2024

Type of visit: Case Management - Incident

On 07/29/2024, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct a case management visit. LPA introduced self, stated the purpose of the visit and was granted entry to the facility. LPA met with Administrator, Margaret Gardea-Benavidas. The purpose of today's visit is to follow up on an incident that was reported to the Fresno CCL office. It was reported that on 04/18/2024, R1 "wandered out of R1's room" and was returned to the facility by individuals residing in a neighboring home. Interviews conducted and records reviewed revealed that R1 exited out of the side door in R1's bedroom. The facility was in the process of updating the alarm system for the facility, and the caregiver on duty did not hear an alarm. A deficiency is being cited in accordance to California Code of Regulations, Title 22, Division 6 on the attached 809D. Exit interview conducted and a plan of correction was reviewed and developed with Administrator. A copy of this report and appeal rights were discussed and provided to Administrator, Margaret Gardea-Benavidas, whose signature on this form confirms receipt of this document.the state’s words, verbatim · CDSS document, Jul 29, 2024

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312(a) · Plan of correction due date: Jul 29, 2024

§1569.312 Basic services requirements: Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2. This requirement was not met as evidenced by: Based on interviews and record reviews, the licensee did not ensure all residents were provided care and supervision when R1 was able to exit the facility without staff knowledge, which posess an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 29, 2024

Plan of correction: Licensee removed the pet door and installed a door sensor chime. POC cleared during inspection.

Type of visit: Required - 1 Year

On 06/18/2024, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an annual inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. Facility staff contacted assistant administrator, Margaret Gardea-Benavidas (AA) via telephone. LPA received verbal permission to conduct the visit with Facility Staff, Alexa Bravo. AA arrived at the end of the inspection. LPA conducted a tour inside and outside of facility. Facility observed to be odor free and at a comfortable temperature. Common areas were furnished well with adequate seating and lighting available. LPA observed an ottoman and chair to be in need of repair in the living room. Resident rooms appeared clean and had required furnishings. LPA observed a camera with audio and the door track in need of cleaning in bedroom 5. LPA observed an adequate supply of linen. Resident bathrooms were properly equipped with securely fastened grab bars in toilet and tub/shower areas, non-skid mats were observed. LPA observed the faucet and light bulb in need of repair in the bathroom between bedroom 3 and 4. Hot water measured between 117.6 - 119.3 degrees F. Kitchen toured, appeared clean, and safe for food preparation. LPA did not observe a 7-day supply of non-perishable. Facility had 2-day supply of perishable food. Exterior tour conducted, all exits open and free of obstructions. Side gate was observed to be self-latching. LPA observed the exit door in the dining area in need of repair. Fire extinguisher serviced on 12/18/2023. Smoke detectors and carbon monoxide detectors observed operational during today’s inspection. Last fire drill conducted on 02/27/2024. All cleaning supplies is locked and inaccessible. LPA observed poster PUB 475 to not be posted per Title 22 regulations. Facility did not have a device with internet access for residents in care LPA reviewed staff and client records. Resident and staff records were observed to be incomplete. S3 did not have a medical assessment on file. AA did not have personnel training records on site, LPA will return to review staff training records. Resident admission agreements were not completed per Title 22 regulation. Facility does not have a planned activity schedule on site. Medications reviewed and observed to have original labels and be administered as prescribed. Medications were found not to be stored as directed. First Aid Kit contained the required supplies. CONTINUED TO 809C Deficiencies are being cited in accordance to California Code of Regulations, Title 22, Division 6 on the attached 809D. Exit interview conducted and plans for correction were reviewed and developed with AA. A copy of this report and appeal rights were discussed and provided to AA, whose signature on this form confirms receipt of this document. LPA is requesting the following documents be submitted to the Fresno CCL office by 07/02/2024: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E) Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A)the state’s words, verbatim · CDSS document, Jun 18, 2024

The state marks this report as 12 pages; the online copy we transcribed has 8. You can request the full file from the county licensing office.

Allegation investigated: Licensee does not ensure that medications are stored locked and inaccessible to residents Licensee does not ensure that staff receive medication training

On 01/26/2024, Licensing Program Analyst (LPA) Walton arrived unannounced to deliver findings on the above allegations. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator, Diana Ellis During the course of this investigation, LPA conducted a facility tour, reviewed records, and interviewed staff. On 10/23/2023, LPA conducted a facility tour. On this date, facility staff were unable to complete the tour with LPA. LPA was granted permission to continue the tour unaccompanied by staff. LPA proceeded to conduct the tour which led to the garage. LPA was able to access the garage and observed the door leading to the garage did not have an operational door chime. LPA exited the facility and opened the refrigerator in the garage and found medication accessible to persons other than employees. LPA received training records for staff listed on the LIC500. Upon review of records, LPA found that 5 out of 9 staff did not have up to date medication training and/or staff did not have medication training recorded. CONTINUED TO 9099C Substantiated Based on observation and record review, the preponderance of evidence standard has been met therefore the allegations: Licensee does not ensure that medications are stored locked and inaccessible to residents and Licensee does not ensure that staff receive medication training, are SUBSTANTIATED. Deficiencies are being issued in accordance with California Code of Regulations, Title 22, Division 6 on the attached 9099D. Exit interview conducted and plans for corrections have been reviewed and developed. A copy of this report and appeal rights were discussed and provided to Administrator, Diana Ellis whose signature on this form confirms receipt of this document.the state’s words, verbatim · CDSS document, Jan 26, 2024 · control 24-AS-20231020160750

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.625(b) · Plan of correction due date: Feb 2, 2024

(b) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 10 hours of training within the first four weeks of employment and four hours annually thereafter… This requirement was not met as evidenced by: Based on record review, the licensee did not ensure that all staff members received annual training. Record reviews revealed that 5 out of 9 staff did not have updated medication training which is a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 26, 2024

Plan of correction: Licensee agrees to write a statement detailing the steps the facility will take to ensure the requirements for section 1569.625 is met, to include the facility’s plan to have the 5 out of compliance staff complete the required medication training.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(2) · Plan of correction due date: Feb 2, 2024

87465(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 was not met as evidenced by: Based on observation, the facility did not comply with section 87465 when medication was found to be accessible to persons other than employees in the refrigerator in the garage, which is an potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 26, 2024

Plan of correction: Administrator removed the medication from the garage and placed the medication in the medication cabinet preventing access to the medication to persons other than staff. POC Cleared.

Allegation investigated: Staff served residents expired food

On 01/26/2024, Licensing Program Analyst (LPA) Walton arrived unannounced to deliver findings on the above allegations. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator, Diana Ellis. During the course of this investigation, LPA conducted a facility tour, reviewed records, and interviewed staff. On 10/23/2023, LPA conducted a facility tour. During the tour LPA observed some food items that were expired/past the “best by” date indicated on the packaging. LPA also observed fruits and vegetables that were discolored. Consistent statements from interviews conducted revealed that the facility accepted/received donated food items. The items that were received were expired or “very close to the best by date” upon receipt. Substantiated Based on observation and interviews conducted, the preponderance of evidence standard has been met therefore the allegation: Staff served residents expired food is SUBSTANTIATED. A deficiency is being cited in accordance to California Code of Regulations, Title 22, Division 6 on the attached 9099D. Exit interview conducted and plans for corrections have been reviewed and developed. A copy of this report and appeal rights were discussed and provided to Administrator, Diana Ellis whose signature on this form confirms receipt of this document. Based on interviews and observation, the allegations: Staff did not treat resident with respect; Staff does not provide a comfortable room temperature for residents; and Staff does not provide adequate amount of food for residents, are UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No deficiencies were issued during this inspection. Exit interview conducted. A copy of this report was discussed and provided to Administrator, Diana Ellis whose signature on this form confirms receipt of this document.the state’s words, verbatim · CDSS document, Jan 26, 2024 · control 24-AS-20231213144812

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(a) · Plan of correction due date: Feb 2, 2024

(a)The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared, and served in a safe and healthful manner... this requirement was not met as evidenced by Based on observation and interviews, the facility did not comply with section 87555 when the facility accepted and used food donations that were past the best buy date, which is a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 26, 2024

Plan of correction: Administrator removed non-perishable foods from the pantry that were past the best buy date and removed discolored fruits and vegetables. Facility has begun shopping more frequently. POC CLEARED.