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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609316
Report Date: 11/15/2022
Date Signed: 11/15/2022 05:56:32 PM


Document Has Been Signed on 11/15/2022 05:56 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:PARADISEFACILITY NUMBER:
197609316
ADMINISTRATOR:RAFIA, BAHMANFACILITY TYPE:
740
ADDRESS:1931 PREUSS ROADTELEPHONE:
(310) 876-1293
CITY:LOS ANGELESSTATE: CAZIP CODE:
90034
CAPACITY:6CENSUS: 5DATE:
11/15/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:11 PM
MET WITH:Eilat Nahum, Manager and Shimon Bayar, AdministratorTIME COMPLETED:
06:00 PM
NARRATIVE
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On 11/15/22, Licensing Program Analyst (LPA) Antonia conducted a case management inspection visit at this facility. LPA was greeted by Eilat Nahum, Manager and Shimon Bayar, Administrator and explained the purpose of the visit. LPA was at this facility in conjunction with complaint #11-AS-20221108092804

During the visit LPA was made aware the facility failed to adhere to regulations Title 22 Section 87355. LPA identified and confirmed staff #1 (S1) worked at this facility from 08/16/22 to 11/15/22 caring for residents without proof of criminal clearance background check. Shimon Bayar, Administrators stated, "S#1 was send home and stated staff will not return to work until she has obtained a California Clearance or a Criminal Record Exemption as required by (CCLD) Community Care Licensing Division.

Based on the information gathered, the licensee violated the California Code Regulations (CCR) of Title 22 sections 87355 Division 6 Chapter 8.


LPA was also inform that several incident were not reported to CCLD. In relation to R#1 based on the information gather Licensee violated the California Code Regulations "CCR" of Title 22 sections 87355 and 87211 Division 6 Chapter 8.


Citation is issued, civil penalties assessed, and exit interview conducted a copy was provided with Caregiver, Nurlelawati Ilyas copy was provided.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonia AlvizarTELEPHONE: (323) 516-4092
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2022
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 11/15/2022 05:56 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: PARADISE
FACILITY NUMBER: 197609316

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/15/2022
Section Cited

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87355(e)(2) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2)Request a transfer of a criminal record clearance as specified in Section 87355(c)d on observation and interviews, the licensee did not comply with the section cited above. The facility did not have approved criminal clearance for S#1.This violation poses an immediate health, safety or personal rights risk to persons in care.
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Based on observation and interviews, the licensee did not comply with the section cited above. The facility did not have approved criminal clearance for S#1.This violation poses an immediate health, safety or personal rights risk to persons in care.
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Type B
11/15/2022
Section Cited

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87211(a)(B)(D) Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department... (B) Any serious injury... occurring while the resident is under facility supervision. (D) Any incident which threatens the welfare, safety or health of any resident...
This requirement is not met as evidenced by:
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Based on record reviews and interviews, the licensee did not comply with the section cited above. The facility failed to submit written report serveral falls and injuries of R #1. This violation poses an potential health, safety or personal rights risk to persons 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: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonia AlvizarTELEPHONE: (323) 516-4092
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2