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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609982
Report Date: 02/12/2024
Date Signed: 02/12/2024 05:47:17 PM


Document Has Been Signed on 02/12/2024 05:47 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:PARADISE IN THE VALLEY LLCFACILITY NUMBER:
197609982
ADMINISTRATOR:COHEN, YEHUDAFACILITY TYPE:
740
ADDRESS:13530 SHERMAN WAYTELEPHONE:
(818) 902-9501
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY:46CENSUS: 39DATE:
02/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:21 AM
MET WITH:Yehuda Cohen, AdministratorTIME COMPLETED:
06:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Yee conducted an unannounced required Annual Inspection using the complete CARE Inspection Tool and initially met with Abriiana Thomas, Staff. Yehuda Cohen, Administrator was contacted by staff and he arrived at 10:11am to conduct the visit. The reason for today's visit was explained.

The facility is a single storey commercial building consisting of a industrial sized kitchen, dining room, a library/activities room, a front office, a medication room and 28 resident rooms. Each of the resident rooms are equipped with a toilet and some rooms have showers. There is a total of 2 common bathrooms. The facility is fire cleared for 36 AMBULATORY and 10 BEDRIDDEN. The facility also has a sprinkler system.

On today's visit, LPA Yee reviewed 10 residents files, 6 staff files, Emergency Disaster Preparedness Plan, and completed the Resident Record-Incident Report domain. Due to time constraints a return visit is needed to complete the other 11 domains not reviewed.


Deficiencies cited California Code of Regulations, Title 22, Division 6, Chapter 8. Immediate Civil Penalties were assessed. Any deficiencies not cited on today's visit will be addressed on the return visit.

Exit interview was conducted APPEALS RIGHTS discussed and a copy was given.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2024
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 02/12/2024 05:47 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: PARADISE IN THE VALLEY LLC
FACILITY NUMBER: 197609982

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(2)
87355 Criminal Record Clearance (e) 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) or


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 6 staff files reviewed, staff Myrna Wharf, hired on 2/1/21, was observed not to be associated to the facility which poses an immediate health, safety or personal rights risk to persons in care. Immediate Civil Penalties of $500 was assessed.
POC Due Date: 02/13/2024
Plan of Correction
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Licensee will review all employee files to ensure that all facility staff have obtained a criminal record clearance and are associated to the facility. Licensee will associate the staff via the Guardian Portal or submit a completed LIC9182 Criminal Background Clearance Transfer Request and a legible copy of the staff''s driver license to the Department to associate the staff by 2/13/24
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2024
LIC809 (FAS) - (06/04)
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