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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608609
Report Date: 07/13/2022
Date Signed: 07/13/2022 01:53:59 PM

Document Has Been Signed on 07/13/2022 01:53 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: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:
07/13/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:22 AM
MET WITH:Moses WakabiTIME COMPLETED:
02:00 PM
NARRATIVE
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On 07/06/2022 at around 10:00 AM, LPA Duguma attempted to conduct an initial complaint visit to the facility and was unable to gain entry. On the same day, 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. 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. On 07/07/2022, the licensee was issued civil penalties and Plan of Corrections (POC). The POCs were received 07/11/2022. On 07/13/2022 at 10:00am, LPA and Community Service Specialist, Quality Assurance (QA) Unishia Deneke arrived at the facility, client #1 (C1) answered the door and allowed entry. When asked if there were any staff present, C1 replied “no”. Upon access to the facility, LPA conducted a physical plant tour and confirmed that staff were not present. LPA contacted the designated administrator, Moses Wakabi, and Mr. Wakabi admitted to the lack of supervision and stated that the clients are “not supposed to be home before 1:00pm.”
Based on the inspection observation and interviews it was concluded that:
· Client #1 (C1) was left at the facility unsupervised.

During the visit, QA discovered medication errors. The Medication Administration Records (MARs) shows that staff, Bridget Alabi, initialed the record and indicated that on 07/09/2022 client #3 (C3) took a prescribed medication, however a physical inspection proved otherwise as the pod was ripped open, yet the pill remained inside. It was also discovered that C1 took medications yet it was not reflected on the July 2022 MARs.

Under Title 22 regulations, the following citations are issued and recorded on LIC809D. In addition to cited deficiencies, an Immediate Civil Penalties of $1,000.00 was issued for the repeat violation of CCR Title 22 regulation section 80078(a).

Exit interview conducted and a copy of the report was issued.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE: DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/13/2022
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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Document Has Been Signed on 07/13/2022 01:53 PM - It Cannot Be Edited


Created By: Abeye Duguma On 07/13/2022 at 12:16 PM
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: 07/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/14/2022
Section Cited
CCR
80078(a)

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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;
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The Licensee will review regulation and submit staff schedules and a written letter certifying 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.
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Based on observations and interviews, licensee failed to ensure required care and supervision to clients in care. On 07/13/2022 at 10:00am, LPA conducted an unannounced visit and clients were left by themselves, without staff supervision which poses an immediate health and safety risk to clients in care.
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Type A
07/14/2022
Section Cited
CCR80075(b)

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80075(b) Health Related Services: Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.
This requirement is not met as evidenced by;
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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 80075. The written letter must be sent to the LPA by the POC due date.
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Based on observations, licensee failed to ensure client was assisted with self-administration of prescription medications. On 07/13/2022 at 12pm, the Quality Assurance Community Service Specialist discovered that a MARs was initialed by staff but the medicati also that medication was taken by a client, yet it was not reflected on the MARs. This poses an immediate health and safety risk to clients in care.
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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: 07/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2022


LIC809 (FAS) - (06/04)
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