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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607670
Report Date: 05/12/2021
Date Signed: 05/17/2021 09:42:07 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME:A PARADISE ELDERLY HOMEFACILITY NUMBER:
197607670
ADMINISTRATOR:YOLANDA BERNARDOFACILITY TYPE:
740
ADDRESS:178 WEST 231ST STREETTELEPHONE:
(310) 876-6917
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY:5CENSUS: 5DATE:
05/12/2021
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
01:39 PM
MET WITH:Yolanda Bernardo TIME COMPLETED:
02:30 PM
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On 05/12/21 at 1:39 pm - 2:30 pm Licensing Program Analyst( LPA), Ernand Dabuet initiated a Collateral visit at this facility. LPA met with Yolanda Bernado Administrator. LPA explained the purpose of this visit is to gather information regarding a current complaint about AMAZING PARADISE HOME CARE complaint number 11-AS-20210329112836,

The visit consisted of an interview with Yolanda Bernardo and one staff #1 (S1) who was responsible for care and supervision for resident #1 (R1) who formally resided at Amazing Paradise Home Care. Details on the interview are documented on LIC 812 crossed reference with AMAZING PARADISE HOME CARE 197608233. Additional interviews were conducted with three (3) residents at this facility residents #2-#4 (R2-R4).

During the visit, LPA requested a copy staff and resident roster for review.

An exit interview was conducted with Yolanda Bernardo, and a hard copy was provided via email.

No deficiencies were cited during the visit.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2021
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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