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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604444
Report Date: 04/08/2024
Date Signed: 04/09/2024 07:22:34 PM


Document Has Been Signed on 04/09/2024 07:22 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:RAYA'S PARADISE, INC.FACILITY NUMBER:
197604444
ADMINISTRATOR:MICHAEL GAMBURDFACILITY TYPE:
740
ADDRESS:1533 N. STANLEY AVE.TELEPHONE:
(323) 969-0316
CITY:LOS ANGELESSTATE: CAZIP CODE:
90046
CAPACITY:6CENSUS: 6DATE:
04/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Brian RosalesTIME COMPLETED:
02:30 PM
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On 04/08/24, 8:45AM Licensing Program Analyst (LPA) Raymond Comer conducted a required unannounced Annual visit to this facility. LPA met with caregiver who contacted the Facility Administrator. Brian Rosales (The Administrator) arrived at the Facility @ 9;15AM, and reason for the visit was discussed. Facility is licensed as a single-story residence, six (6) non-Ambulatory, of which, three (3) may be bedridden. Hospice waiver for six (6). Facility has six (6) private resident bedrooms and four (4) bathrooms.

At 9:45AM, LPA conducted a tour of the physical plant with the Administrator and observed the following:

Physical plant was inspected for cleanliness and condition. Facility’s main door is the primary entry/exit access. Screening area is located immediately upon entrance. Visitor Sign-in sheet, hand sanitizer, gloves and masks are available. Covid 19 prevention protocols are posted. Hand washing, coughing etiquette, and other necessary signage are posted in the bathroom and throughout the facility. Room temperature is comfortable; wall thermostat displays a setting of 78.0°F. within the required range. Side door is located west of house, exiting to back yard. All trash cans were observed to be covered. The facility has submitted an approved Mitigation and Infection Control plan. Required postings are prominently displayed and observed to be current at the facility. Disaster drills were last conducted on 4/02/2024.
Fire Detection/Protection systems are present at facility. Multiple smoke alarms are installed, hardwired and interconnected. Two (2) Carbon monoxide alarms are installed. Both Smoke and Carbon monoxide detectors were tested and function properly. Fire extinguishers are located in Kitchen area and Hallway areas and are fully charged, with inspection service date: 03/26/2024.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) -596-4373
LICENSING EVALUATOR NAME: Raymond ComerTELEPHONE: 818-401-8655
LICENSING EVALUATOR SIGNATURE:
DATE: 04/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2024
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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: RAYA'S PARADISE, INC.
FACILITY NUMBER: 197604444
VISIT DATE: 04/08/2024
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Medications are stored in a secured medications cart in dining room area and are inaccessible to residents. A First Aid kit is accessible and stored in a dining room area cabinet. Medications are listed in centrally stored medication cart and destruction record log.
Laundry area is located and secured in hallway storage compartment near the kitchen. Laundry soaps and other cleaning agents are stored and inaccessible to residents. Linen storage observed to have adequate supply of linen and towels.

Bedrooms are observed as clean with sufficient lighting, properly furnished with bedding, linens, at least one chair, and nightstand.

Bathrooms were observed to be clean and sanitary with necessary supplies and required safety fixtures (grab bars, anti-slip floor stripping). Hot water temperature measured at 116.5°F. Within the required range.

Garage is attached to the house and observed to be locked and inaccessible to residents. Garage is also used as storage for frozen foods, extra water and PPE supplies.

Outdoor (backyard) area observed to have a shaded patio, with table with sufficient seating for the residents. Outdoor furniture observed to be in good condition. There are no bodies of water in the facility.

Resident records were reviewed for current IPP and/or Needs and Services plans, physician report, and admission agreements. Resident records appeared to be complete and current.



Staff records were checked. Staff files contain criminal record clearances and are associated to this facility.
Staff records appear to be complete and current.

There were no immediate health and safety hazards observed during the day of inspection. Exit interview conducted and a copy of this report was given
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) -596-4373
LICENSING EVALUATOR NAME: Raymond ComerTELEPHONE: 818-401-8655
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2024
LIC809 (FAS) - (06/04)
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