197603340-1-28-2023-11-AS-PSCT-CNHP8N-20230128100549

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197603340
Report Date: 01/28/2023
Date Signed: 01/28/2023 10:05:58 AM

Document Has Been Signed on 01/28/2023 10:05 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	EXCLUSIVE RAYA'S PARADISE, INC.		FACILITY NUMBER:	197603340
ADMINISTRATOR:	ISRAEL & MOTI GAMBURD		FACILITY TYPE:	740
ADDRESS:	341 N. LA JOLLA AVE.		TELEPHONE:	(323) 851-2517
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90048
CAPACITY:	6	CENSUS: 4	DATE:	01/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Brian Rosales		TIME COMPLETED:	11:30 AM

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On 1/28/23 at 9:00am, Licensing Program Analyst (LPA) Perry Scott conducted an unannounced required annual visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA was met by Brian Rosales, Executive Director, and then LPA conducted a risk assessment for COVID-19, based on the assessment, the facility is clear of Covid-19 infection. After the assessment, the purpose of today’s visit was explained. The facility is licensed for six non-ambulatory residents aged 60 and over; hospice waiver approved for one (1). The facilities liability insurance was checked and received. The annual fees for the facility are current.

As part of the inspection, my primary focus was on infection control. LPA observed the facility’s infection control practices: LPA observed a sanitizing station at the facility entrance. PPE supplies are readily available to staff and residents, and additional supplies are stored. Sufficient paper, cleaning, and disinfecting supplies were observed. The facility has the mandated COVID infection control posters.

LPA Scott and Mr. Rosales toured the inside and outside grounds of the facility. The one-story residential house consists of living room, kitchen, dining room, six (6) resident bedrooms, six (6) bathrooms, laundry, shaded patio area, and garage. LPA observed that all six (6) bedrooms are private with a private bathroom. Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident’s personal belongings was observed. There are currently four (4) residents in the facility.

All resident bathrooms were checked, sufficient soap and towels were observed. Toilets and water faucets worked properly, grab bars were secure, the shower was free of mold/mildew. The water temperature measured at 117.3 degrees F. Comfortable temperature was maintained in the facility. There are no bodies of water on the premises and the facility was free from obstructions and hazards inside and out. LPA observed that the residents looked well cared for and the staff was attentive to their needs.

Report continued on page 2 of LIC809-C

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Perry Scott	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: EXCLUSIVE RAYA'S PARADISE, INC.	FACILITY NUMBER: 197603340
	VISIT DATE: 01/28/2023

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LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Centrally stored medications were observed to be locked in a cabinet, and inaccessible to residents in care. Dual/ hardwired Carbon Monoxide/ Smoke Detectors were tested and found to be in operating condition. LPA observed that all fire extinguishers were fully charged and operable. The first aid kit was available and fully stocked. All disinfectants, toxins, knives, and cleaning solutions were locked and inaccessible to residents.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations (Located in common areas and restrooms). LPA observed staff was wearing face coverings, and the required postings were posted throughout the facility. LPA observed the facility has a 60-day supply of Personal Protective Equipment (PPE). LPA’s temperature was taken as well as instructions on where to sign in for the visitor’s logbook.

LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing (www.cdss.ca.gov) for Provider Informational Notices (PIN) and for any updates relating to COVID-19 guidance and other new policies.

No deficiencies were cited during this visit.

An exit interview was conducted, and a copy of this facility evaluation report was provided to Executive Director, Brian Rosales.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Perry Scott	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2023

LIC809 (FAS) - (06/04)

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