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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604445
Report Date: 09/23/2023
Date Signed: 09/23/2023 05:00:11 PM


Document Has Been Signed on 09/23/2023 05:00 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:
197604445
ADMINISTRATOR:MOTI GAMBURDFACILITY TYPE:
740
ADDRESS:1156 N. GARDNER ST.TELEPHONE:
(323) 815-8858
CITY:WEST HOLLYWOODSTATE: CAZIP CODE:
90046
CAPACITY:11CENSUS: 8DATE:
09/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:07 PM
MET WITH:Administrator Moti GamburdTIME COMPLETED:
05:00 PM
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On 09/23/2023 at 2:09 Am Licensing Program Analyst (LPA) David España conducted an unannounced 1-Year Annual visit to the facility. Upon arriving at the facility, LPA met Administrator Brain Rosales and Administrator Moti Gamburd 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 cases).

The facility has an approved mitigation plan on file. Disaster drill was last conducted on 1//29/2023. A tour of the physical plant was conducted at 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 facility maintains a temperature at 76 degrees Fahrenheit.



The facility has 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 seven (07) and (08). 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. LPA observed sharps to be locked and stored in a drawer between the kitchen sink and stove inaccessible to residents.

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. LPA observed and tested the carbon monoxide detector on the wall near the laundry to operational and functioning.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (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)
Page: 1 of 3


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: 197604445
VISIT DATE: 09/23/2023
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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. 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 toilet area. The water temperature measured between 105F and 120F 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.

LPA observed these areas to be appropriately furnished with tables and chairs and adequate lighting. Activities are stored in (02) cupboard in the living room storing arts and crafts, board games, puzzles etc. LPA confirmed 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. 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.

LPA observed medication cart and stored medication in the dining room to be locked and storing medication inaccessible to residents. 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 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. Required posting are observed to be complete and current and displayed properly at the facility. Exit interview conducted and copy of this report issued to Administrator Brain Rosales and Administrator Moti Gamburd.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (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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