197604444-9-23-2023-31-AS-DESA-CVXRS3-20230923131603

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197604444
Report Date: 09/23/2023
Date Signed: 09/23/2023 01:16:14 PM

Document Has Been Signed on 09/23/2023 01:16 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
Lookup Error,
, CA

FACILITY NAME:	RAYA'S PARADISE, INC.		FACILITY NUMBER:	197604444
ADMINISTRATOR:	MICHAEL GAMBURD		FACILITY TYPE:	740
ADDRESS:	1533 N. STANLEY AVE.		TELEPHONE:	(323) 969-0316
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90046
CAPACITY:	6	CENSUS: 4	DATE:	09/23/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:39 AM
MET WITH:	Administrator Brain Rosales		TIME COMPLETED:	01:30 PM

NARRATIVE

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On 09/23/2023 at 8:39 am Licensing Program Analyst (LPA) David España conducted an unannounced 1-year Annual visit to the facility. Upon arriving at the facility, LPA met with staff shortly after the Administrator Brain Rosales, who assisted with the visit. The purpose of today’s visit was discussed. Upon arrival at the facility, LPA conducted a risk assessment at the front door (No COVID-19 at this time).

The facility is licensed as a single-story residence 6 Non-Ambulatory, of which 3 may bedridden. Hospice Waiver For 6. The facility has six (6) bedrooms and five (4) bathrooms currently occupying 4 residents. There is no staff room. Smoke detectors and carbon monoxide detectors were tested and function properly. LPA and staff toured of the physical plant was conducted with staff for compliance, safety, maintenance and operational Title 22 requirements. The kitchen appeared clean and the appliances and fixtures functional. LPA observed a sufficient amount of perishable and non-perishable food at the facility; properly stored in the garage. Sharp objects are stored in a locked drawer in the kitchen. Locked medications are placed in a locked cabinet in the kitchen.

LPA observed the resident bedrooms were properly furnished with at least one chair, nightstand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. While conducting tour of the facility LPA observed facility cameras. LPA observed grab bars and non-skid mats in all bathrooms. Residents have sufficient amounts of supplies for personal hygiene. The hot water was measured between 105F-120F per Title 22 regulations requirements. LPA observed the common areas were checked for cleanliness and furniture was checked for functionality. All areas were clean, sanitary and in good repair. LPA observed the laundry room which is located in the right hallway along the residents' bedroom. Laundry detergents, cleaning supplies, pesticides, and/or toxins are also stored in the laundry room. The laundry room was observed to be locked and inaccessible to residents.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2023

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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Document Has Been Signed on 09/23/2023 01:16 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
Lookup Error,
, CA

FACILITY NAME: RAYA'S PARADISE, INC.	FACILITY NUMBER: 197604444
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(4)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above. LPA LPA and Administrator Brian Rosales Farxiga observed and reviewed missing the following medications for Resident 2-3 (R2-3), which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/25/2023
	Plan of Correction
1 2 3 4	The administrator/licensee agreed to have all medications in order in internal system for residents ensuring resident safety. The licensee shall submit plan of correction to ensure cited deficiency do no reoccur at the facility. The administrator of records shall update the resident's/staff's in services plans by 09/25/2023 (david.espana@dss.ca.gov).

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.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2023

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
Lookup Error,
, CA

FACILITY NAME: RAYA'S PARADISE, INC.	FACILITY NUMBER: 197604444
	VISIT DATE: 09/23/2023

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LPA observed patio has an outdoor furniture within a shaded area. There is a structure in the backyard and currently being used as old equipment and other supplies storage. There is also a shed in the backyard which is being used as a tool and maintenance supplies storage. There is no body of water in the facility. LPA observed medication in the dining room area cabinet to be locked and inaccessible to residents in care. Medications are listed on the centrally stored medication and destruction record log. The first aid kit was complete and stored in the medication cabinet.

LPA conducted a complete file review of four (4) staff records. Staff records appear to be complete and updated.

Disaster drill was last conducted on 1//29/2023.

Technical Assistance:

Resident Rights/Information - Technical Assistance: 87468(c)(2)(A)

Disaster Preparedness - Technical Violation: 1569.695(a)(5)

Type B:
Incidental Medical and Dental - Type B: 87465(h)(4) -

Required posting are observed to be complete and current and displayed properly at the facility.

No deficiencies observed during today’s visit, copy of this report provided to facility representative, Administrator Brain Rosales.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2023

LIC809 (FAS) - (06/04)

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