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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607670
Report Date: 03/29/2023
Date Signed: 04/21/2023 08:28:44 AM


Document Has Been Signed on 04/21/2023 08:28 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY 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: 4DATE:
03/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Director Yolanda BernardoTIME COMPLETED:
11:36 AM
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On 03/29/23, Licensing Program Analyst (LPA) Lizeth Villegas conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with the Director Yolanda Bernardo and the purpose of today’s visit was explained. The facility is licensed to serve two (2) ambulatory, and three (3) bedridden residents ages 60 and above. Fire cleared for two (2) bedridden residents in room #3 with the 3rd approved to be placed in either of the two remaining rooms. Hospice waiver approved for three (3) resident. No residents have Restricted Health Care Conditions and none are utilizing postural supports or protective devices.

The facility is a single story home and consists of the following: three (3) resident bedrooms, two (2) bathrooms one (1) of which is for residents and one (1) is for visitors and staff, staff working area, living room, kitchen, dining room, attached garage which houses the washer and dryer, an additional refrigerator for extra food storage and an outdoor shaded area.

LPA conducted a records review of four (4) residents records, ten (10) staff records, four (4) residents Personal & Incidental Records and reviewed the facility disaster plan. All resident & Staff records were complete. The facility disaster plan was current and in compliance with Title 22 at the time of visit. Last disaster drill was completed on 02/28/23. LPA reviewed (4) Client Medication Administration Records and did not observed any discrepancies at the time of visit.

All resident rooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed, walls and floors were clean and in good repair, bed linens, comforters and bath towels were fully stocked. Bathrooms were found to be within Title 22 regulation, toilets and water faucets worked properly, shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to clients. The water temperature properly measured between 105-120F, bathroom #1 .

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2023
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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: A PARADISE ELDERLY HOME
FACILITY NUMBER: 197607670
VISIT DATE: 03/29/2023
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was 117.8F & bathroom #2 was 117.3F, kitchen sink was 116.9F

Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Carbon monoxide detector was observed and operational. Smoke detectors were working properly, two (2) fire extinguishers were fully charged, one (1) located and mounted in the hallway and one (1) located in the garage, toxins and knifes were locked and inaccessible to clients. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked, first aid manual up to date. A landline was observed, one (1) cordless phone located at the staff working area and one (1) cordless phone located in the kitchen. Outside grounds were toured and no bodies of water were observed. Exits/ Walkways around the home were free of debris and hazards.

During todays visit LPA did not observe any deficiencies.

Exit interview conducted with Director Yolanda Bernardo and a copy of this report was provided.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023
LIC809 (FAS) - (06/04)
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