197610439-5-15-2024-31-AS-MAGN-D5ASS2-20240515140712

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610439
Report Date: 05/15/2024
Date Signed: 05/15/2024 02:08:36 PM

Document Has Been Signed on 05/15/2024 02:08 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	PARADISE SENIOR LIVING		FACILITY NUMBER:	197610439
ADMINISTRATOR:	APOYAN, ANGELA		FACILITY TYPE:	740
ADDRESS:	8435 AURA AVE		TELEPHONE:	(818) 626-3338
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91324
CAPACITY:	6	CENSUS: 3	DATE:	05/15/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Angela Apoyan-Administrator		TIME COMPLETED:	02:00 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) Mariana Agban conducted a Pre-Licensing Inspection with Administrator Angela Apoyan. A Change in Ownership (CHOW) Application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL) on May 15, 2023. A fire clearance was approved on October 31,2023 for two (2) ambulatory residents, three (3) non ambulatory residents and one (1)bedridden resident, for a total capacity of six. The bedridden fire clearance is for room #4. A dementia plan of operation has been submitted. Hospice waiver has been requested for three (3) residents which is pending approval of Manager. The garage is to be used as a garage only. The smoke alarms and carbon monoxide detector are battery operated and functional. The facility has one fire extinguisher that was purchased on July 11, 2023. The fire extinguisher is located in dining room area. A tour of the physical plant was initiated at approximately 10:20 am and the following was observed: The facility is a two-story building. The facility sketch that was submitted to CCL was just for the first floor. From the first floor, there is a stairwell that leads to the 2nd floor. The stairwell has a door that is being kept locked. On the 2nd floor, there are two bedrooms each has a private bathroom. The 2nd floor is furnished. Administrator stated that the 2nd floor is being used by the landlord. The landlord lives out of the country and once or twice a year comes back to the country. Administrator mentioned that currently future staff live in one of the rooms on the 2nd floor. KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, microwave oven and sink. There were adequate supplies of perishable and nonperishable food and dining ware to accommodate a maximum capacity of six (6). Knives were observed locked in a kitchen drawer.BEDROOMS: There are four (4) bedrooms designated for residents use. Bedroom #1 and #2 are private rooms for ambulatory residents. Bedrooms #3 and #4 are shared rooms with bedroom #4 having a bedridden fire clearance (per STD 850). The applicant furnished the resident bedrooms with beds, night stand, chairs, dresser, bedding and linen. The bedrooms have sufficient lighting and closet space. (Continue on 809C)

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PARADISE SENIOR LIVING	FACILITY NUMBER: 197610439
	VISIT DATE: 05/15/2024

NARRATIVE

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BATHROOMS: The facility has two (2) bathrooms for the resident's use. Both bathrooms were observed to have the proper fixtures, grab bars, and non-skid mats. The hot water delivered in the bathrooms measured at 109.4 degrees. COMMON AREAS: These included the living room and dining room. The living room was equipped with furniture, a television, tables and chairs. The dining area has a large dining room table to accommodate six (6). There were no visible immediate hazards.

GARAGE/LAUNDRY ROOM: The washer and dryer is located in the garage, which is kept locked. The garage is also used as extra storage for non-perishable and emergency food supplies and water. There is another refrigerator in the garage for additional perishable food items.

MEDICATIONS: The medications are kept locked in a kitchen cabinet.

Resident Files: LPA conducted a file review of random resident records to insure compliance of licensing forms. Resident files are kept locked in the office/workstation area.

Staff Files: Staff files are also kept in a locked cabinet in the office/workstation area.

OFFICE/STAFF WORKSTATION: There is a staff workstation located at the entrance of the facility.

SURROUNDING GROUNDS: The driveway, passageways and entrance to the home were clear of obstruction. All entry and exit doors have a functional auditory alert when the doors open. The backyard of the facility has a patio and backyard furniture to accommodate the six (6) residents. The facility backyard has sufficient yard space.
In addition to the Pre-Licensing inspection, a Component III power point presentation was also held.

Pursuant to Title 22, Division 6 of the CA Code of Regulations, the facility's physical environment appears to be compliant and ready for licensure. CAB will be advised and a copy of this report provided.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024

LIC809 (FAS) - (06/04)

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