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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607979
Report Date: 09/20/2023
Date Signed: 09/22/2023 12:14:22 PM


Document Has Been Signed on 09/22/2023 12:14 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:
197607979
ADMINISTRATOR:MICHAEL GAMBURDFACILITY TYPE:
740
ADDRESS:851 N. GARDNER STREETTELEPHONE:
(323) 951-0598
CITY:LOS ANGELESSTATE: CAZIP CODE:
90046
CAPACITY:4CENSUS: 2DATE:
09/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:51 PM
MET WITH:TIME COMPLETED:
03:30 PM
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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 1:51pm 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. The single-story house is a duplex with access between the two (02) facilities. and consisting of a common area, dining area, two (2) bedrooms, one (1) full bathrooms for residents, a half (1/2) restroom for staff and currently occupying two (2) residents. There is one entrance being utilized at the facility, there are required posters at the main door. Smoke detectors and Carbon Monoxide detector were tested and function properly. Facility disaster drills was conducted on 01/31/2023.

The facility maintains a comfortable temperature at 75°F. The smoke detectors and Carbon Monoxide detectors were tested and function properly. Fire extinguishers are located in the common area 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 the appliances and fixtures functional. Kitchen is being used to prepare food for residents in both facilities address 851 and 849. Facility has access to at least two (2) days perishable and seven (7) days non-perishable food. Frozen foods are wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. There are additional non-perishable foods properly stored in the garage. Sharp objects are stored in a locked drawer in the kitchen.

(Continued on 809-C)
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia AlvizarTELEPHONE: (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: 197607979
VISIT DATE: 09/20/2023
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Laundry Room: LPA observed the laundry room located adjacent to the kitchen inaccessible to residents observed to be clean and free from obstruction and debris. LPA observed a plastic shed locked located outside the facility exit door in the laundry room to be locked and storing toxins, bleach, laundry soap and cleaning supplies.
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.
Bathrooms: LPA observed all bathrooms to be clean, properly supplied and had functional fixtures. LPA observed grab bars in both bathrooms. Residents full bathroom had non-skid mat in shower and sufficient personal hygiene supplies. The half (1/2) restroom is designated for staff. Hot water temperature readings measured within the required 105-120 degrees Fahrenheit.
Common Areas: These included the common and dining area. The common areas were checked for cleanliness and furniture was checked for functionality. All areas were clean, sanitary and in good repair. Locked medications are placed in a locked cabinet located in the common area. At 2:35pm LPA observed residents watching television in the common area located at address 849.
Medications: LPA observed the medication cart located at the entrance of the facility observed to be locked and inaccessible to residents storing medication. The facility has two(2) first aid kits and personal protected equipment (PPE) screening station at the entrance of the facility.
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 849 Raya's Paradise, located in the rear of the facility, which stores PPE supplies, 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 MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia AlvizarTELEPHONE: (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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