197607055-9-20-2023-31-AS-AALR-CVUSEP-20230920134905

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607055
Report Date: 09/20/2023
Date Signed: 09/20/2023 01:50:20 PM

Document Has Been Signed on 09/20/2023 01:50 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	EXCLUSIVE RAYA'S PARADISE, INC.		FACILITY NUMBER:	197607055
ADMINISTRATOR:	MOTI MICHAEL GAMBURD		FACILITY TYPE:	740
ADDRESS:	849 N. GARDNER STREET		TELEPHONE:	(323) 951-0598
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90046
CAPACITY:	5	CENSUS: 3	DATE:	09/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Executive Director, Brian Rosales		TIME COMPLETED:	01:48 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	Licensing Program Analyst (LPA) Antonia Alvizar conducted an unannounced Annual Required visit to this facility. LPA met with Executive Director, Brian Rosales and explained the reason for the visit. A tour of the physical plant was conducted with Brian at 9:45am for compliance with safety, maintenance, and operational requirements. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Facility is a single-story house in a residential neighborhood and consisting of a common area, three (3) bedrooms, one (1) full bathroom and a half (1/2) restroom currently occupying three (3) residents. There is one entrance being utilized at the facility, there are required posters at the main door. Smoke detectors and Carbon Monoxide detectors were tested and function properly. Facility disaster drills was conducted on 01/31/2023. The facility maintains a comfortable temperature at 73°F. Fire extinguishers are located in the kitchen and at the end of the hallway near the bedrooms. Fire extinguishers were fully charged and last serviced in 02/24/2023. Cleaning supplies and toxic substances are inaccessible to residents. Kitchen: The kitchen appeared clean and fixtures functional. The kitchen is currently not being used and all food preparation is being done at kitchen with address 851 Raya's Paradise located across the hallway. Bedrooms: The residents’ bedrooms were properly furnished and had adequate lighting and closet space. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. (Continued on 809-C)

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: EXCLUSIVE RAYA'S PARADISE, INC.	FACILITY NUMBER: 197607055
	VISIT DATE: 09/20/2023

NARRATIVE

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Continued from 809)
Bathrooms: LPA observed all bathrooms to be clean, properly supplied and had functional fixtures. LPA observed grab bars in both bathrooms. The full bathroom had non-skid mat in shower. Residents have enough personal hygiene supplies. Hot water temperature readings measured within the required 105-120 degrees Fahrenheit.

Common Areas: The living room has a television, a couch and three (3) recliner chairs. The common areas were checked for cleanliness and furniture was checked for functionality. All areas were clean, sanitary and in good repair. At 9:15am LPA observed residents having breakfast in the shared dining area at address 851 Raya's Paradise located across the hallway..

Surrounding Grounds (Outdoors): There was a shaded area with proper furniture for outdoor use in the front and rear of the facility. There are no bodies of water and firearms on the premises. There is a shared garage with 851 Raya's Paradise, located in the rear of the facility, which stores personal protected equipment (PPE), emergency food, extra Non-perishable food, medical and maintenance supplies.

In addition to the physical plant LPA conducted a file review for all residents and staff regularly scheduled. Staff have current first aid and training documentation showing required training completed. Resident records observed to be complete at this time.

Per California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, deficiencies were not observed/cited. Exit interview conducted and Copy of Report will be emailed.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023

LIC809 (FAS) - (06/04)

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