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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609312
Report Date: 08/10/2022
Date Signed: 08/10/2022 04:52:48 PM


Document Has Been Signed on 08/10/2022 04:52 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:A PARADISE IN THE VALLEYFACILITY NUMBER:
197609312
ADMINISTRATOR:DER-APRAHAMIAN, ARSENFACILITY TYPE:
740
ADDRESS:7754 TEXHOMA AVETELEPHONE:
(323) 821-1419
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY:6CENSUS: 4DATE:
08/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Arsen Der-Aprahamian TIME COMPLETED:
04:00 PM
NARRATIVE
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On 08/10/22 at 1:50 p.m Licensing Program Analyst (LPA) Joscelyn Martinez arrived at the facility to conduct an unannounced annual inspection. Upon arrival LPA met with staff and then met with Administrator Arsen Der-Aprahamian. The purpose of the visit was explained. Entrance interview conducted.
A physical plant tour was conducted at 2:05 p.m and the following was observed:

Infection Control: Covid-19 infection control signage were observed outside of the facility. Proper signage was also observed inside in the common areas. Facility has sufficient PPE supplies for more than 30 days. Food Inspection/Kitchen: LPA observed there to be sufficient stock of one-week non-perishable foods and two-day perishable foods. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers in the kitchen. Sharps are centrally stored in a locked area. A bottle of cleaning chemical was observed in an unlocked cabinet under the kitchen sink. LPA had staff remove the bottle of chemical and properly store in a locked cabinet. Smoke detectors/carbon monoxide are located throughout the facility and are hardwired. Smoke detectors and carbon monoxide detectors were tested and appear to be functional. Facility has a fire door leading to three (3) of the residents’ bedroom. Door was operational once the fire alarm was tested. Fire extinguisher was observed to be fully charge and purchased within the year. Common Areas: All common areas were observed to be clean and properly furnished. Resident Rooms: Facility has four (4) bedrooms designated for resident use. Facility has two live-in staff which have their own designated dwelling. All four (4) bedrooms were toured and appear to be clean and properly furnished. LPA observed additional bedding and linens sufficient for all of the residents. All rooms have adequate lighting and furniture. The facility maintains an upstairs dwelling area that is inaccessible to residents. Bathrooms: There are three (3) bathrooms in the facility of which two (2) are designated for resident’s use. LPA observed all bathrooms to be cleaned. The hot water was tested and measured 111.6 F which is in regulation. All trash cans located in the bathrooms had tight fitting lids. Showers have adequate grab bars and non-skid mats.

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn MartinezTELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2022
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


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: A PARADISE IN THE VALLEY
FACILITY NUMBER: 197609312
VISIT DATE: 08/10/2022
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Outside: LPA toured the outside area and observed appropriate outdoor furniture with a shaded covered area for residents. There are no bodies of water. There is an outside dwelling area that is inaccessible to residents.

Citation issued, exit interview conducted, appeals and copy of report provided to Administrator.

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn MartinezTELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 08/10/2022 04:52 PM - It Cannot Be Edited

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: A PARADISE IN THE VALLEY
FACILITY NUMBER: 197609312

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/10/2022
Section Cited

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87705(f)(2) Care of Persons with Dementia
Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
This requirement was not met evidenced by observation.
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LPA observed cleaning supply bottle located in a unlocked cabinet under the kitchen sink.
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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: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn MartinezTELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3