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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604445
Report Date: 05/26/2022
Date Signed: 05/26/2022 01:56:59 PM


Document Has Been Signed on 05/26/2022 01:56 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:RAYA'S PARADISE, INC.FACILITY NUMBER:
197604445
ADMINISTRATOR:MOTI GAMBURDFACILITY TYPE:
740
ADDRESS:1156 N. GARDNER ST.TELEPHONE:
(323) 851-2517
CITY:WEST HOLLYWOODSTATE: CAZIP CODE:
90046
CAPACITY:11CENSUS: 8DATE:
05/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:53 AM
MET WITH:Brain RosalesTIME COMPLETED:
01:55 PM
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Licensing Program Analyst (LPA) LaQueena Lacy arrived at the facility at 10:48am on 05/26/2022 to conduct a One (1) year Required Infection Control visit. LPA meet manager Brian Rosales and explained the purpose of this visit. The facility has an approved mitigation plan on file.

A tour of the physical plant was conducted at 10:55am and the following was observed:

The facility has eight (08) bedrooms and two (02) bathrooms. The facility has a fire clearance for eleven (11) non-ambulatory with a hospice waiver for (11), with one (01) resident receiving hospice. The facility has one main entrance being used, there are required Covid-19 prevention signage (hand washing, coughing etiquette, and physical distancing) posted. The PPE screening station is located on a table near the entrance equipped with sufficient PPE readily accessible, thermometer, hand sanitizer, gloves, mask, and sign in sheet at the time of visit. The facility maintains a temperature at 76 degrees Fahrenheit. The facility has three (03) fire extinguishers located, on the wall between the dining room and kitchen, behind the front door, and at the end of the hallway near rooms seven (07) and (08) to all have a service tag dated 05/05/2022 and 05/06/2022.
Kitchen: At 11:00am LPA observed the kitchen to be clean and free from obstruction. Appliances observed to be in good repair. The facility has a food waiver on file. At 11:04am LPA observed sharps to be locked and stored in a drawer between the kitchen sink and stove inaccessible to residents.
Continued on LIC809C
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena LacyTELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2022
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 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: RAYA'S PARADISE, INC.
FACILITY NUMBER: 197604445
VISIT DATE: 05/26/2022
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Laundry Room: At 11:09am LPA observed the laundry room located across from room (03) in the hallway, equipped with an electric enviroblind that is operated by a switch to be covering and enclosing the laundry machines inaccessible to residents, clean and clear from obstruction and storing laundry supplies. LPA observed a storage cabinet storing extra linens and blankets. At 11:11am LPA observed and tested the carbon monoxide detector on the wall near the laundry to operational and functioning.

Bedrooms: At 11:15am LPA observed all bedrooms to be appropriately furnished with
sufficient lighting. LPA observed appropriately bed linen and comforters on all beds. One (1) out of (8) bedrooms are double occupancy. All bedrooms observed to be clean and clear from obstruction.
Bathroom: At 11:27am LPA observed (2) bathrooms, one (1) bathroom located near room (02) is not being used to give showers, LPA did not observe any grab bars located near the shower but observed near the toliet area. The water temperature measured at 106.7 and 115.7 degrees Fahrenheit. LPA observed appropriate grab bars in shower and toilet area with appropriate non-skid mats. Bathrooms are stocked and equipped with soap and paper towels. Hand towels are not shared. In a cabinet in the bathroom extra hand and drying towels are stored.
Living, dining room and common areas: At 11:34am LPA observed these areas to be appropriately furnished with tables and chairs and adequate lighting. Observed to be neat and clean. Activities are stored in (02)cupboard in the living room storing arts and crafts, board games, puzzles etc. At 11:43am the fire alarm system was tested and observed to be
working, it is hard wired and interconnected throughout facility. The facility has fire sprinklers throughout the facility. A cupboard in the living room is storing resident files. At 11:48am LPA observed a small refrigerator located in the living room against the wall to be locked and storing medications and inaccessible to residents. The first aid kit is stored on a cart near the patio exit door in the living room.
Medications: LPA observeda medication cart at 11:47am stored in the dining room to be locked and storing medication inaccessible to residents.
Continued on LIC809C
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena LacyTELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: RAYA'S PARADISE, INC.
FACILITY NUMBER: 197604445
VISIT DATE: 05/26/2022
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Backyard: At 11:50am LPA observed the outside area and surrounding grounds of the facility which was clean and clear from debris and obstruction. The facility has a covered patio area with chairs and a small table for lounging. The area behind the facility has a table and owning with chairs for seating, and extra table and chairs for lounging underneath a covered umbrella shaded area. No bodies of water observed or located on the premises. LPA observed a detached garage at 11:59am to be locked and using a keypad for entry, storing extra personal care items, incontinent supplies, PPE, wheelchairs and bed frames. A plastic shed observed to be locked and storing brooms, cleaning agents and buckets inaccessible to residents. The front porch of the facility also has a shaded area with chairs and tables for lounging, with a water fountain that was not in operation during the time of the visit.

LIC9102TA (Technical Assistance) issued, No deficiencies cited, exit interview conducted, and a copy of report issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena LacyTELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4