<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608609
Report Date: 07/07/2022
Date Signed: 07/07/2022 11:17:15 AM

Document Has Been Signed on 07/07/2022 11:17 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:PARADISE HOMEFACILITY NUMBER:
197608609
ADMINISTRATOR:MUSTAPHA ALABIFACILITY TYPE:
735
ADDRESS:20319 CEDARCREEK STREETTELEPHONE:
(661) 367-6524
CITY:CANYON COUNTRYSTATE: CAZIP CODE:
91351
CAPACITY: 4CENSUS: 4DATE:
07/07/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:42 AM
MET WITH:Na Kia WashingtonTIME COMPLETED:
11:20 AM
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 Analyst (LPA) Abeye Duguma and Licensing Program Manager (LPM) Naira Margaryan arrived to the facility to complete a case management visit initiated on 07/06/2022.
On 07/06/2022 at around 10:00 AM, LPA Duguma attempted to conduct licensing visit to the facility and was unable to gain entry. While waiting outside, LPA glance through the window and observed two individuals present at the facility. One of them was coming close to the window, but was not opening the door.
LPA Duguma spoke with the Administrator, who indicated that he is out of country.
The Administrator was unable to indicate who was the Administrator’s designee at the time of his absence.
Even after speaking with the Administrator, Mustapha Alabi, LPA was unable to gain entry and left the facility.
At approximately 3:30pm, LPA Duguma visited the facility again and the staff #1 (S1) allowed the LPA to enter the facility. At 3:40pm LPA spoke with staff #1 (S1) and S1 informed the LPA that she started her shift at 1:00pm when the clients came back from the day programs.
S1 indicated that the two clients of the facility did not attend the Day Program and were present at the facility between 9am and 1pm. In addition, S1 stated that morning shift staff left at 9am and admitted that, between 9am-1pm, two facility clients were left in the facility without staff supervision.

Based on the inspection observation and interviews it was concluded that:
· LPA was refused entry to the facility.
· Two clients; Client #1 (C1) and Client #2 (C2) were left at the facility unsupervised.
· The Administrator was out of country and failed to notify Licensing office and designate qualified substitute to assist him during his absence.
· The staff working at the facility had no knowledge of the staff schedule.
Under Title 22 Regulations, the following citations are issued and recorded on LIC809D. In addition to cited deficiencies, Immediate Civil Penalties of $500.00 per citation were issued for the citation of CCR TItle 22 regulations sections 80044(a)(2) and 80078(a)
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 07/07/2022 11:17 AM - It Cannot Be Edited


Created By: Abeye Duguma On 07/07/2022 at 10:02 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PARADISE HOME
FACILITY NUMBER: 197608609

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/08/2022
Section Cited
CCR
80044(a)(2)

1
2
3
4
5
6
7
Inspection Authority of the Licensing Agency. (a) The licensing agency shall have the inspection authority specified in Health and Safety Code Sections..1533 and other H&S sections (2) ...any..employee..of CDSS... may,.. enter.. inspect any place providing personal care, supervision,.. at any time, with
1
2
3
4
5
6
7
The Licensee will review regulation and submit a written letter certifing that, moving forward, they will ensure to follow and adhere to CCR TItle 22 80044 -- Inspection Authority of the Licensing Agency. The written letter must be sent to the LPA by the POC due date.
8
9
10
11
12
13
14
 or without advance notice... This requirement is not met as evidenced by; Based on observations and interviews, the licensee did not allow LPA entry to the facility after identification. This poses an immediate health and safety hazard to clients in care.
8
9
10
11
12
13
14
Type A
07/08/2022
Section Cited
CCR80078(a)

1
2
3
4
5
6
7
80078 Responsibility for Providing Care and Supervision; (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement is not met as evidenced by; Based on observations and interviews, licensee failed to ensure required care and supervision to clients in care. On 07/06/2022 from 9:00am-1:00pm, clients were left by themselves, withouit staff supervision.
1
2
3
4
5
6
7
The Licensee will review regulation and submit a written letter certifing that, moving forward, they will ensure to follow and adhere to CCR Title 22 80078 -- Responsibility for Providing Care and Supervision; The written letter must be sent to the LPA by the POC due date.
8
9
10
11
12
13
14
This poses an immediate health and safety hazard to clients in care.

8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Naira Margaryan
LICENSING EVALUATOR NAME:Abeye Duguma
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 07/07/2022 11:17 AM - It Cannot Be Edited


Created By: Abeye Duguma On 07/07/2022 at 10:46 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PARADISE HOME
FACILITY NUMBER: 197608609

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/08/2022
Section Cited
CCR
85064(f)

1
2
3
4
5
6
7
85064 Administrator’s Qualifications and Duties; (f) When the administrator is absent from the facility there shall be coverage by a designated substitute, who meets the qualifications of Section 80065, who shall be capable of and responsible and accountable for, management and administration of the facility... This requirement is not met as
1
2
3
4
5
6
7
The Licensee will review regulation and submit a written letter certifing that, moving forward, they will ensure to follow and adhere to CCR TItle 22 85064 -- Administrator’s Qualifications and Duties. The written letter must be sent to the LPA by the POC due date.
8
9
10
11
12
13
14
evidenced by; Based on observations and interviews, the licensee did not ensure coverage by a qualified designee. Licensee left the country without assigning substitue for administrator during his absence. This poses an immediate health and safety hazard to clients in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Naira Margaryan
LICENSING EVALUATOR NAME:Abeye Duguma
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2022


LIC809 (FAS) - (06/04)
Page: 3 of 3