197608521-10-3-2023-31-AS-MCAA-CW9SX4-20231003141518

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608521
Report Date: 10/03/2023
Date Signed: 10/03/2023 02:16:05 PM

Document Has Been Signed on 10/03/2023 02:16 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	EXCLUSIVE RAYA'S PARADISE, INC.		FACILITY NUMBER:	197608521
ADMINISTRATOR:	MOTI MICHAEL GAMBURD		FACILITY TYPE:	740
ADDRESS:	852 N. SIERRA BONITA AVENUE		TELEPHONE:	(323) 782-1842
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90046
CAPACITY:	6	CENSUS: 4	DATE:	10/03/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Brian Rosales		TIME COMPLETED:	02:30 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 Analysts (LPAs) Chris Alemoh and Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with the administrator, Brian Rosales and explained the reason for the visit. At approximately 11:00am, with the assistance of staff and the administrator, LPAs took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms and carbon monoxide are dual and is battery operated. The fire extinguisher is located at the back entry way. The charge date is March 1, 2023. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Properly labeled medications were locked in one of the kitchen cabinets. Facility does food preparation at 846 Sierra Bonits St. The facility has a food waiver to prevent contamination and keep served meals warm or cold. Bedrooms: There were three (3) bedrooms designated for residents' use. Three of the bedrooms, in use by residents were were properly furnished with appropriate beddings and linens with sufficient lighting. Bathrooms: There are three (3) bathrooms designated for residents' use. Both bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 115 degrees Fahrenheit. Cleaning supplies are being stored in the hallway bathroom. Common Areas: These included the living room and dining area. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: EXCLUSIVE RAYA'S PARADISE, INC.	FACILITY NUMBER: 197608521
	VISIT DATE: 10/03/2023

NARRATIVE

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Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor
use. The outdoor area was free of hazards. The laundry area and detergents are located by the kitchen.

Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms. Files are maintained electronically.

Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms. Files are also maintained electronically.

Medications: Medication and Medication Records were review for proper documentation.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted. A Copy of the Report Issued.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023

LIC809 (FAS) - (06/04)

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