197609982-12-21-2022-29-AS-AASO-CMBM5N-20221221081836

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609982
Report Date: 12/20/2022
Date Signed: 12/21/2022 08:19:28 AM

Document Has Been Signed on 12/21/2022 08:19 AM - 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. #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:	(818) 902-9501
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91405
CAPACITY:	46	CENSUS: 35	DATE:	12/20/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Yehuda Cohen		TIME COMPLETED:	03:15 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) Angel Ascencio conducted an unannounced required annual visit to the above facility. LPA Ascencio met with the Administrator Yehuda Cohen and explained the reason for the visit. This annual had a specific emphasis on infection control practices and procedures. At 1:25 p.m., LPA, along with the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards. BEDROOMS: All resident rooms are set up with beds, night stands, lamps, chests of drawers, chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean linen; which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if needed) and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds. The facility has a total of 28 bedrooms - 17 are shared bedrooms, and 9 are private. RESTROOMS: There are about 20 total bathrooms at the facility. The resident bathrooms consist on a sink and toilet. There are 4 shower rooms with non-skid materials. Hot water temperature was tested throughout the facility and was within normal ranges between 105.0 F and 120.0 F. COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, common seating area and dining room furniture was observed to be in good condition. Chairs were observed to be at least 6 (six) feet apart for social distancing. Continued on LIC 809 - C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

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: 12/20/2022

NARRATIVE

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The LPA observed the required postings in the common hallway. Fire extinguishers were observed to be serviced within the last year. The facility smoke alarm system and carbon monoxide detector was tested and operated normally at the time of visit. The medication room was observed to be locked and contained at least 30 days of worth of medication. A locked staff room was observed that contained the laundry room and laundry supply. The outdoor patio has a covered outdoor area equipped with furniture for resident use. The There are no bodies of water noted.

KITCHEN: Kitchen knives are stored in a cabinet in the kitchen. The supply of dishes,
utensils, pots, pans and drink ware is adequate. The freezer was maintained at zero degrees
Fahrenheit (0*F) and the refrigerator was maintained at 40*F. The supply of perishable and nonperishable
food is adequate. There are no pesticides (poisons) or toxins stored in any food storage area or preparation
area with utensils. Appliances in the kitchen were clean and all appeared functional. Trash cans had
tight fitting lids. Kitchen, laundry and house cleaning supplies are stored in a locked staff room. No flies or other vermin were observed

INFECTION CONTROL: During today’s visit, the LPA spoke with Administrator regarding the
facility’s infection control practices at 2:15 p.m. There is 1 entry into the facility. The LPA noted that the facility is allowing visitors for both indoor and outdoor visitation. The LPA observed an adequate supply of Personal Protective 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. The facility’s policies and procedures as it pertains to infection control are adequate.
No citations were issued during today’s visit.

Recommendations:

- Upon entry, continue to symptom screen staff, resident and visitors per PIN guidelines.

Exit interview conducted, and a copy of the report provided to Admin via email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

LIC809 (FAS) - (06/04)

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