197603340-1-23-2025-11-AS-AINZ-DD7RWK-20250123122315

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197603340
Report Date: 01/23/2025
Date Signed: 01/23/2025 12:23:33 PM

Document Has Been Signed on 01/23/2025 12:23 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	EXCLUSIVE RAYA'S PARADISE, INC.		FACILITY NUMBER:	197603340
ADMINISTRATOR/ DIRECTOR:	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	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	01/23/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:50 AM
MET WITH:	Brian Rosales-Executive Director		TIME VISIT/ INSPECTION COMPLETED:	12:30 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

On 1/23/2025, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Brian Rosales /Administrator. LPA explained the purpose of today’s visit. The facility is licensed to serve (6) elderly adults ages 60 and above, of which (6) can be non-ambulatory. The facility has an approved hospice waiver for (1). The facility current has (3) hospice 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 Iniguez and the Administrator toured the physical plant. There were no bodies of water or obstructions on the premises. LPA inspected a total of (5) bedrooms and (5) bathrooms. The beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. The bathrooms were found to be within Title 22 regulations and were operational. Smoke and carbon monoxide detectors were in operable condition. The water temperature ranged from 115°F to 116.2°F, and the room temperature ranged from 76°F to 78°F.

The evaluation Report continues on the next page, LIC 809-C, providing further details of the inspection findings.

Eva M Alvarez	TELEPHONE: (323) 629-7047
Alfonso Iniguez	TELEPHONE: 323-981-1755
	DATE: 01/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: EXCLUSIVE RAYA'S PARADISE, INC.	FACILITY NUMBER: 197603340
	VISIT DATE: 01/23/2025

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
26
27
28
29
30
31
32

During the visit, LPA Iniguez observed that the facility was clean, sanitary, and appropriately furnished. Storage areas for personal hygiene were in place. The kitchen was inspected, and there was sufficient perishable and non-perishable food available, which was adequately maintained. All fire extinguishers were charged and operable. The last Fire/Disaster Drills were conducted on 1/8/25.

A review of (3) residents' service files and (4) staff personnel files was maintained in order. LPA reviewed (3) Medication Administration Records (MARs) and found no discrepancies.

LPA observed the facility's infection control practices. All mandated inspection control posters were displayed throughout the facility. A copy of liability insurance will be email to LPA. Facility Annual Fess current.

Deficiency cited under California Code of Regulations, Title 22, Division 6, Chapter 8. See details below:

-Facility exceeded hospice waiver.

-No recent reappraisal and TB test for one of the resident.

-Unlocked cleaning supplies found underneath the sink.

-Administrator not associated at facility at the time of visit-Civil Penalty Rendered for $500.

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. *

An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Brian Rosales / Administrator.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025

LIC809 (FAS) - (06/04)

Page: 2 of 5

Document Has Been Signed on 01/23/2025 12:23 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: EXCLUSIVE RAYA'S PARADISE, INC.	FACILITY NUMBER: 197603340
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Storage Space and Access

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation), the licensee did not comply with the section cited above in having unlocked cleaning supplies under the kitchen sink which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/24/2025
	Plan of Correction
1 2 3 4	Licensee will adhere to title 22 regulations. As plan of correction, administrator will conduct an in-service training for all facility staff regarding keeping cleaning supplies locked at all times. Proof of training will be sent to LPA Iniguez via email before POC due date.

Section Cited

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in not having the adminstrator associated at the facility at the time of the visit. which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/24/2025
	Plan of Correction
1 2 3 4	Licensee will adhere to title 22 regulations. As plan of correction, administrator will associate himself to the facility. Proof of training will be sent to LPA Iniguez via email before 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.

Eva M Alvarez	TELEPHONE: (323) 629-7047
Alfonso Iniguez	TELEPHONE: 323-981-1755
	DATE: 01/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 01/23/2025 12:23 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: EXCLUSIVE RAYA'S PARADISE, INC.	FACILITY NUMBER: 197603340
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

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: (A) Communicable tuberculosis. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in not having a TB test on file for one of the residents which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/03/2025
	Plan of Correction
1 2 3 4	Licensee will adhere to title 22 regulations. As plan of correction, administrator will get TB test from hospice company. Proof of training will be sent to LPA Iniguez via email before POC due date.

Section Cited

Reappraisals

(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in not having a current reappraisal which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/03/2025
	Plan of Correction
1 2 3 4	Licensee will adhere to title 22 regulations. As plan of correction, administrator will get reappraisal test from hospice company. Proof of training will be sent to LPA Iniguez via email before 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.

Eva M Alvarez	TELEPHONE: (323) 629-7047
Alfonso Iniguez	TELEPHONE: 323-981-1755
	DATE: 01/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 01/23/2025 12:23 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: EXCLUSIVE RAYA'S PARADISE, INC.	FACILITY NUMBER: 197603340
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Hospice Care for Terminally Ill Residents

(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility, when all of the following conditions are met: (2) The licensee remains in substantial compliance with the requirements of this section, with the provisions of the Residential Care Facilities for the Elderly Act (Health and Safety Code Section 1569 et seq.), all other requirements of Chapter 8 of Title 22 of the California Code of Regulations governing Residential Care Facilities for the Elderly, and with all terms and conditions of the waiver. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in exceding the current hospice waiver which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/31/2025
	Plan of Correction
1 2 3 4	Licensee will adhere to title 22 regulations. As plan of correction, licensee will apply as soon as posible for a increased of hospice waiver via email before 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.

Eva M Alvarez	TELEPHONE: (323) 629-7047
Alfonso Iniguez	TELEPHONE: 323-981-1755
	DATE: 01/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025

LIC809 (FAS) - (06/04)

Page: 5 of 5