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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608521
Report Date: 09/09/2025
Date Signed: 09/09/2025 01:19:28 PM

Document Has Been Signed on 09/09/2025 01:19 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:EXCLUSIVE RAYA'S PARADISE, INC.FACILITY NUMBER:
197608521
ADMINISTRATOR/
DIRECTOR:		MOTI MICHAEL GAMBURDFACILITY TYPE:
740
ADDRESS:852 N. SIERRA BONITA AVENUETELEPHONE:
(323) 782-1842
CITY:LOS ANGELESSTATE: CAZIP CODE:
90046
CAPACITY: 6CENSUS: 4DATE:
09/09/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Brian RosalesTIME VISIT/
INSPECTION COMPLETED:
01:10 PM
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On 09/09/25, 10:15 am, Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannounced annual inspection visit. LPA met with the Administrator, and reason for the visit was discussed. Facility is licensed as a single-story residence, fire clearance for six (6) non-ambulatory; Of which, one (1) may be bedridden in room#1. Hospice waiver for six (6). Facility has three (3) bedrooms and three (3) bathrooms.

At 10:35 am, LPA conducted a tour of the physical plant with the Administrator and observed the following:

Physical plant was inspected for cleanliness and condition. Facility’s main door is the primary entry/exit access. Screening area is located immediately upon entrance. Auditory alarm sensors are present on all exits. Visitor Sign-in sheet, hand sanitizer, gloves and masks are available. Room temperature is comfortable; wall thermostat displays a setting of 74.0°F., within the required range. Approved Mitigation and Infection Control plan is on file. Hand washing, coughing etiquette, and other necessary signage are prominently displayed throughout the facility. Required postings observed to be current. Disaster drills were last conducted: September, 2025.

Kitchen area is clean and clear of clutter. LPA observed refrigerator, microwave, stove/oven, dishwasher, and sink to be operational. Knives/Sharps are stored in a locked kitchen drawer inaccessible to residents. A two-day supply of perishable food was observed as properly stored and labeled. A seven-day supply of nonperishable food is stored and available. Dish soap, cleaning solutions, and toxins are stored in a locked lower cabinet underneath the kitchen sink and inaccessible to residents.

[LIC 809C-continued]

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Raymond Comer
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: EXCLUSIVE RAYA'S PARADISE, INC.
FACILITY NUMBER: 197608521
VISIT DATE: 09/09/2025
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Fire Detection/Protection system is present in the facility. Multiple dual smoke alarm/ carbon monoxide detectors are installed, hardwired, and interconnected. Detectors were tested and function properly. LPA observed two (2) fire extinguishers located in the front and rear areas of the facility. Extinguishers indicate full charge; display service date: 02/07/2025.

Medications are stored in a secured medication cart in den area adjacent to the kitchen and inaccessible to residents. Medications are listed on a centrally stored medication and destruction record log. A First Aid kit is complete and stored inside the medication cart.

Laundry At 11:30 AM, LPA observed laundry area located in the hallway, across from bedroom #1. Laundry is secured by an electric rolling shutter activated by a key switch only accessible to staff. Laundry soaps and other cleaning agents are stored and inaccessible to residents. Hallway area storage cabinets were observed to contain fresh towels, linens and blankets, sufficient for residents.

Commons: LPA observed living room area as clean, organized and clear of obstruction. Furnishings observed in good condition and provide adequate seating for residents. Activities were observed as stored in a dresser located in the living room which contains arts and crafts, board games, puzzles etc.

Bedrooms are observed as clean with sufficient lighting, properly furnished with sufficient closet space, bedding, linens, at least one chair, and nightstand.

Bathrooms were observed to be clean and sanitary with necessary personal hygiene supplies and required safety fixtures (grab bars, anti-slip floor striping). Hot water temperature measured at 110.0°F. Within the required range. Towels and washcloths are not shared.

Garage is detached from the house and observed to be locked and inaccessible to residents. Garage stores emergency water, incontinence and PPE supplies.

Outdoor (backyard) area observed to have a shaded patio, with tables and seating sufficient for residents and visitors. Outdoor furniture was observed to be in good condition. There are no bodies of water in the facility.

[LIC 809C-continued]

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Raymond Comer
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2025
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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: EXCLUSIVE RAYA'S PARADISE, INC.
FACILITY NUMBER: 197608521
VISIT DATE: 09/09/2025
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Resident records are stored in secured\locked hallway cabinet and inaccessible to residents. Records were reviewed for current IPP and/or Needs and Services plans, physician report, and admission agreements. Resident records appeared to be complete and current.

Staff records are stored in secured office area and inaccessible to residents. Staff files contain criminal record clearances and are associated to this facility. Staff records appear to be complete and current.

There were no health and safety hazards observed during this inspection. Exit interview conducted and a copy of this report was given.
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Raymond Comer
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2025
LIC809 (FAS) - (06/04)
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