197604445-8-20-2024-31-AS-RCOR-D8BTMZ-20240820145158

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197604445
Report Date: 08/20/2024
Date Signed: 08/20/2024 02:52:09 PM

Document Has Been Signed on 08/20/2024 02:52 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:	197604445
ADMINISTRATOR:	MOTI GAMBURD		FACILITY TYPE:	740
ADDRESS:	1156 N. GARDNER ST.		TELEPHONE:	(323) 815-8858
CITY:	WEST HOLLYWOOD	STATE: CA	ZIP CODE:	90046
CAPACITY:	11	CENSUS: 6	DATE:	08/20/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Brian Rosales		TIME COMPLETED:	03:00 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 08/20/24, 10:15 AM, Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannounced Annual visit to this facility. LPA met with Facility Administrator, Brian Rosales, and reason for the visit was discussed. Facility is licensed as a single-story residence, fire clearance for ten (10) non-ambulatory, and one (1) bedridden. Hospice waiver for eleven (11). Facility has eight (8) total bedrooms; seven shared and one private, and two (2) bathrooms. At 10:30 AM, 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. Auditory alarm sensors are present on all exits. Visitor Sign-in sheet, hand sanitizer, gloves and masks are available. Room temperature is comfortable; wall thermostat displays a setting of 75.0°F., within the required range. An approved Mitigation and Infection Control plan is on file. Hand washing, coughing etiquette, and other necessary signage are prominently displayed throughout the facility. Required postings observed to be current. Disaster drills were last conducted in March, 2024. Fire Detection/Protection system is present in the facility. Multiple dual smoke alarm and carbon monoxide detectors are installed, hardwired, and interconnected. Detectors were tested and function properly. LPA observed Three (3) 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 bedroom#7 and bedroom #8. Extinguishers display service date: 02/16/2024. [LIC 809C-continued]

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) -596-4373
LICENSING EVALUATOR NAME: Raymond Comer	TELEPHONE: 818-401-8655
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024

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: 197604445
	VISIT DATE: 08/20/2024

NARRATIVE

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Kitchen: At 10:50AM, LPA observed kitchen as clean, equipped with a functional stove, multiple appliances, with an adequate supply of perishables and non-perishable food. Storage cabinets were observed to contain emergency dry food, condiments, and can goods. Food is observed as properly labeled and stored. Kitchen cabinets store dishes, plastic, paper goods and utensils. Knives and sharps are secured in a locked drawer and inaccessible to residents.

Medications are stored in a secured medication cart in kitchen area and are inaccessible to residents. Medications are listed on a centrally stored medication and destruction record log. A First Aid kit is complete and stored inside living room cabinet.

Laundry At 11:15 AM, LPA observed the hallway area. The laundry is located in the hallway, across from bedroom #3, and is secured by an electric rolling shutter activated by a key switch only accessible to staff. Laundry soaps and other cleaning agents are stored and inaccessible to residents. Hallway area storage cabinets were observed to contain fresh towels, linens and blankets, sufficient for residents.

Commons: LPA observed all common areas of the facility, including the living room and resident dining area. Common areas were clean and organized. Furnishings provide adequate seating for residents and are in good condition. Activities were observed as stored in a cupboard section of the living room, along with arts and crafts, board games, puzzles etc.

Bedrooms are observed as clean with sufficient lighting, properly furnished with sufficient closet space, bedding, linens, at least one chair, and night stand.

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 111.0°F. Within the required range.

[LIC 809C-continued]

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) -596-4373
LICENSING EVALUATOR NAME: Raymond Comer	TELEPHONE: 818-401-8655
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024

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: 197604445
	VISIT DATE: 08/20/2024

NARRATIVE

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Garage is detached from the house; observed to be locked by keypad-only entry, and inaccessible to residents. Garage is also used as storage for PPE supplies, incontinence supplies, wheelchairs, bedframes, emergency food, and other supplies for resident needs.

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. A locked shed in the backyard stores tools and maintenance supplies. All trash cans were observed to be covered. There are no bodies of water in the facility.

Resident records: Secured cabinet in the kitchen area is locked and inaccessible to residents. A total of six (6) Resident files 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: Secured cabinet in the kitchen area is locked and inaccessible to residents. A total of six (6) Staff files were reviewed. Criminal record clearances were present, and Staff are associated to this facility. Staff records appear to be complete and current.

There were no immediate health and safety hazards observed at the time of this inspection. Exit interview conducted and a copy of this report was given to facility representative, Administrator Brain Rosales.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) -596-4373
LICENSING EVALUATOR NAME: Raymond Comer	TELEPHONE: 818-401-8655
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024

LIC809 (FAS) - (06/04)

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