197609494-4-7-2022-31-AS-LQLY-CD9TSU-20220407145942

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609494
Report Date: 04/07/2022
Date Signed: 04/07/2022 03:00:56 PM

Document Has Been Signed on 04/07/2022 03:00 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:	RAYA'S PARADISE, INC.		FACILITY NUMBER:	197609494
ADMINISTRATOR:	GAMBURD, MOTI		FACILITY TYPE:	740
ADDRESS:	846-848 N. SIERRA BONITA AVE.		TELEPHONE:	(323) 851-7515
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90046
CAPACITY:	11	CENSUS: 9	DATE:	04/07/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:25 AM
MET WITH:	Robin Culver		TIME COMPLETED:	02:57 PM

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) LaQueena Lacy arrived at the facility at 10:30am on 04/07/2022 to conduct a One (1) year Required Infection Control visit. LPA meet with Robin Culver and Brian Rosales and explained the purpose of this visit. The facility has an approved mitigation plan on file. A tour of the physical plant was conducted at 10:35am and the following was observed: The facility has nine (9) bedrooms and eight (8) bathrooms located in the bedrooms currently occupying (9) residents, and one (1) main bathroom for staff and visitors. The facility has one main entrance being used, there are required Covid-19 prevention signage (handwashing, coughing etiquette, and physical distancing) posted. The PPE screening station is located on the medication cart located behind the front door entrance equipped with sufficient PPE readily accessible, a wall thermometer, hand sanitizer, gloves, mask, and electronic sign in sheet at the time of visit. The facility maintains a temperature at 76 degrees Fahrenheit. The facility has a fire clearance for eleven (11) non-ambulatory, (11) may be bedridden with a hospice waiver for (11). The facility has auditory alarms on all exits and requires a code for entry and exit. Kitchen: At 10:38am LPA observed the kitchen to be clean and an adequate supply of perishables and non-perishable food. There is an open pantry space area storing dry food, condiments, and can goods on shelving units. Food was properly labeled and stored. The shelving units are also storing dishes, plastic, and paper utensils goods. The emergency food is stored and observed to be in the open pantry space area of the kitchen. The basement level also is occupying an office, an entry from the parking garage. All visitors and must enter the facility through the main access entry point on the main level. Two fire extinguisher in the kitchen area, (1) in the kitchen dated 06/09/2021, second near the elevator dated 06/08/2021. Fire extingusher located in the hallway near the kitchen dated 06/09/2021. Laundry Room: At 10:43am LPA observed the laundry room, which is located adjacent to the kitchen Continued on LIC809C.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena Lacy	TELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022

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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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: RAYA'S PARADISE, INC.	FACILITY NUMBER: 197609494
	VISIT DATE: 04/07/2022

NARRATIVE

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inaccessible to residents, clean and clear from obstruction and storing laundry supplies. The janitor closet observed to be locked clean and clear from obstruction.
Continued on LIC809CBedrooms: At 10:46am LPA observed all bedrooms to be appropriately furnished with sufficient lighting. LPA observed appropriately bed linen and comforters on all beds. One (1) out of (9) bedrooms are double occupancy. All bedrooms observed to be clean and clear from obstruction.
Bathroom: At 10:46am LPA observed (8) bathrooms out of (9) which are located inside of the bedrooms to be clean and in proper operation. (1) out of (9) bathrooms are designated for staff and visitors water temperature measured at 106.7 degrees Fahrenheit. LPA observed appropriate grab bars in shower and toilet area with appropriate non-skid mats in (1) out of (8) bathrooms located in resident’s room number (9). The bathroom designated for staff and visitors also have appropriate grab bars in shower and around toilet area. The water temperature range in resident bathrooms from 105.1 between 113.2 degrees Fahrenheit. Hand towels are not shared. Bathrooms stocked and equipped with soap and private towels use.

Backyard: At 10:53am LPA observed the outside area and surrounding the facility it was clean and clear from obstruction. The facility has a table and owning for seating, chairs, and extra table for lounging underneath a shaded area. The back yard provides access to the sister facilities sharing the same back yard space located on the property which is labeled with it's own individual address. No bodies of water observed or located on the premises. LPA observed a detached garage at 10:58am to be locked and storing extra personal care items, incontinent supplies, cleaning products, PPE, constructions supplies, and tools. The front of the facility also has a shaded area with chairs and tables for lounging, with a water fountain that does not retain water.

Living, dining room and common areas: At 11:06am LPA observed these areas to be appropriately furnished with tables and chairs and adequate lighting. Observed to be neat and clean. Activities are stored in a cupboard in the dining room/living room. At 11:13am the fire alarm system was tested and observed to be working, it is hard wired and interconnected throughout facility. The facility has fire sprinklers throughout the facility. The facility has a carbon monoxide detector located in the dining room tested to be operational and functioning. Fire extinguisher observed to be hanging on the wall in the living room behind the entrance of the facility service tag dated 06/08/2021, second extinguisher located near the back exit of the facility near room number (9) with a service tag attached dated 06/09/2021. There is also a kitchenet located in the living/dining room equipped with a small refrigerator storing juice, and water.
Continued on 809C.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena Lacy	TELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022

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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: RAYA'S PARADISE, INC.	FACILITY NUMBER: 197609494
	VISIT DATE: 04/07/2022

NARRATIVE

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The kitchen cabinet is storing snacks. At 11:17am LPA observed sharps to be stored and locked in a kitchen top drawer adjacent to the kitchen sink. LPA observed no toxins, or anything being stored underneath the kitchen sink.The cabinet drawers are also storing video surveillance equipment. Door labeled fire alarm control panel to be storing extra linen, comfortable and towels.

Medications: LPA observed at 11:23am the locked medication cabinet located behind the front entrance of the facility. LPA observed the first aid kit and manual located and stored in the medication cart.

California Code of Regulations (Title 22, Division 6, Chapter 8, 87303 Maintenance and Operation), deficiency cited on LIC809D. Exit interview conducted. Copy of report, and appeal rights issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena Lacy	TELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 04/07/2022 03:00 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: RAYA'S PARADISE, INC.	FACILITY NUMBER: 197609494
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(e)(4)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (4) Grab bars shall be maintained for each toilet, bathtub and shower used by residents. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the appropriate grab bars were not installed around the toilet or shower area at the time of visit, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/14/2022
	Plan of Correction
1 2 3 4	Licensee will install grab bars in all bathrooms in the shower and toilet area. Licensee will submit a written statement within 24 hours, of intent to utilize the bathroom for staff and visitors until all grab bars are installed. Licensee will submit proof by photograhs to LPA by due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena Lacy	TELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022

LIC809 (FAS) - (06/04)

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