197603340-1-4-2024-11-AS-EGOZ-CZ6U6D-20240104141810

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197603340
Report Date: 01/04/2024
Date Signed: 01/04/2024 02:18:24 PM

Document Has Been Signed on 01/04/2024 02:18 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
EL SEGUNDO ASC, 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; 6	CENSUS: 6	DATE:	01/04/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	09:55 AM
MET WITH:	Brian Rosales.		TIME COMPLETED:	02:15 PM

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Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced annual required visit to the above facility. LPA met with License Vocational Nurse (LVN) Arman Ahangarzadeh and the purpose of the visit was discussed. LPA was granted access to the facility. Executive Director Brian Rosales joined LPA to conduct the visit shortly after. Facility is licensed to serve six (6) non-ambulatory residents aged 60 and over. This facility has an approved hospice waiver for one (1) resident. The facility currently has six (6) residents.

The facility is a single-story structure located in a residential neighborhood. It consists of six (6) bedrooms, six (6) bathrooms, a living room, kitchen, dining room, laundry area, an outdoor shaded patio area, and a detached garage.

LPA and Mr. Rosales toured the inside and outside grounds of the facility. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place. The water temperature measured between 105.0 F and 120.0 F in all bathrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions. Comfortable temperature was maintained in the facility.

The kitchen was checked and observed to be within Title 22 regulations. Sufficient perishable and non-perishable food supply was maintained adequately. All sharps, toxins, cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. A review of Medication Administration Records was maintained in order and accurate. The facility has a landline telephone on-site in working condition. Medications were centrally stored and properly locked. Smoke detectors and carbon monoxide detectors were operational and working properly. Fire extinguisher was fully charged.

Continued on LIC 809-C

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Elvira Gonzalez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024

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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: EXCLUSIVE RAYA'S PARADISE, INC.	FACILITY NUMBER: 197603340
	VISIT DATE: 01/04/2024

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A stocked First Aid kit along with manual was available. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards.

During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents. There are sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The facility has an approved CCLD Mitigation Plan.

During this inspection LPA did not observe any deficiencies, therefore no citations were issued at this time.

An exit interview was conducted, and a copy of Report and Appeal Rights was provided to Executive Director Brian Rosales.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Elvira Gonzalez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024

LIC809 (FAS) - (06/04)

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