197609982-2-4-2022-29-AS-SWAR-CBC2EJ-20220204162002

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609982
Report Date: 02/04/2022
Date Signed: 02/04/2022 04:21:08 PM

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	PARADISE IN THE VALLEY LLC		FACILITY NUMBER:	197609982
ADMINISTRATOR:	COHEN, YEHUDA		FACILITY TYPE:	740
ADDRESS:	13530 SHERMAN WAY		TELEPHONE:	(323) 806-0786
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91405
CAPACITY:	46	CENSUS: 27	DATE:	02/04/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Sonia Aquino, Designee		TIME COMPLETED:	04:30 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) Salia Walker arrived at the facility unannounced to conduct a required Annual visit. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Designee Sonia Aquino at 2:00 p.m., and explained the reason for the visit. The LPA toured the physical plant areas inside and outside with the Designee at 2:07 p.m., to ensure there are no health and safety hazards. Kitchen: The kitchen area appeared clean and sanitary. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food, and has an arranged meal delivery contract with ‘Grand Valley Health Care Center.’ Food in the refrigerator/freezer were properly labeled. All knives and cleaning supplies were observed to be properly stored and locked at time of visit. Hot water measured 115.9 degrees Fahrenheit at 2:20 p.m. Bedrooms: The LPA observed resident bedrooms which were furnished with clean linens, appropriate furnishings, and sufficient lighting. Restrooms: Each resident restroom is designed as a ½ bathroom; the facility has designated shower rooms throughout the facility. The resident bathrooms and shower rooms are properly equipped with grab bars and shower rooms are equipped with non-skid material. Hot water was randomly tested throughout the facility inspection; temperatures ranged between 105.0 – 119.8 degrees Fahrenheit in common/ private restrooms. Common Areas: Five (5) Fire extinguishers were observed throughout the facility fully charged, with an annual Maintenance expiration date of 09/22/2024. The building is a one-level facility, which consists of offices, an activity room, a library, medication room, laundry room, multiple supply closets, staff room, kitchen/dining room, and multiple shower rooms. The LPA observed common areas, including furniture and activity equipment, to be clean and in good condition. Continue on LIC 809C..

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:	DATE: 02/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2022

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PARADISE IN THE VALLEY LLC	FACILITY NUMBER: 197609982
	VISIT DATE: 02/04/2022

NARRATIVE

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Surrounding Grounds: Entry/exits were free of obstruction. Medication room: First aid kit, medications, and medication records are kept in the medication room. The First Aid Kit was complete with a thermometer, scissor, tweezers, bandage and a first aid manual.
BACKYARD: The patio has covered outdoor areas equipped with furniture for resident use. There were no bodies of water noted.
INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator via telephone at 3:56 p.m. regarding the facility’s infection control practices. Upon entry, the facility had a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE), and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility does not have a confirmed case of COVID-19 at this time, and the LPA reviewed facility’s policies and procedures as it pertains to infection control.

Exit interview conducted. A copy of the report was provided.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:	DATE: 02/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2022

LIC809 (FAS) - (06/04)

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