198600693-3-13-2023-11-AS-WGIS-CPVT3Z-20230313142309

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600693
Report Date: 03/13/2023
Date Signed: 03/13/2023 02:23:17 PM

Document Has Been Signed on 03/13/2023 02:23 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	PARADISE PALACE 11		FACILITY NUMBER:	198600693
ADMINISTRATOR:	LOFTON, JANICE		FACILITY TYPE:	735
ADDRESS:	5134 W 136TH ST		TELEPHONE:	(310) 355-5997
CITY:	HAWTHORNE	STATE: CA	ZIP CODE:	90250
CAPACITY: 3		CENSUS: 3	DATE:	03/13/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:54 AM
MET WITH:	Detric Johnson		TIME COMPLETED:	03:00 PM

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On 03/13/23, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced required annual visit using the full CARE Inspection Tools. Upon arrival at the facility, LPA Gibbs called and did a risk assessment; based on the assessment, the facility is clear of Covid-19. LPA Gibbs met with House Manager, Detric Johnson, and explained the purpose of today’s visit. During today’s visit we were joined by Administrator, Janice Lofton and Licensee, Brenda Chandler. The facility is approved for three (3) developmentally disabled clients ages 18-59 years. Currently there are (3) residents residing in the facility, and all (3) were present during the visit.

Structure The facility is a single-story home located in a residential area. The house consists of (3) client bedrooms, two (2) bathrooms, living room, dining room, family room, kitchen, backyard and enclosed patio. There is a detached garage in the back which contains administrator’s office.

Physical Plant LPA and House Manager, both toured the inside and outside grounds of the facility. In the back there is an enclosed patio area with table and chairs. The backyard has two seat swing. The front and back yard are landscaped and well maintained. LPA did not observe any bodies of water on the premises. All walkways are clean, clear, and free of obstructions, debris, or hazards.
Bedrooms All residents have a private bedroom. All resident’s bedrooms were inspected and found to contain the required furniture, including bed, dresser, chair, nightstand with a lamp, and ample storage space for personal belongings. Beds and bedding supplies were in good condition. LPA observed all beds to have the required linens including a mattress cover, fitted sheets, blankets, comforter and pillow. All rooms were observed to have ample lighting.

Linens & Hygiene LPA observed an ample supply of bed linens, blankets, and towels in the cupboard in the hallway. In resident’s rooms there is an additional supply of comforters and linens stored. Also in the garage is an additional supply of comforters. LPA observed an ample supply of hygiene products in the bathroom and additional supply is stored in a cabinet in the garage and is inaccessible to residents.

Cont on LIC809-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2023

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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: PARADISE PALACE 11	FACILITY NUMBER: 198600693
	VISIT DATE: 03/13/2023

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Bathrooms All bathrooms were checked, sufficient liquid soap and paper towels were observed. Both bathrooms were fully functioning and in good repair. All handrails were securely fastened to the wall. LPA observed a shower chair and a nonskid mat. LPA observed an ample supply of hygiene products for residents. The water temperate in the bathrooms measured between 116.3-degrees and 117.3 degrees Fahrenheit.

Kitchen LPA toured the kitchen area and observed a three-day supply of perishable and a seven-day supply of non-perishable food. Additional food is stored in cabinets and freezer in the garage. LPA observed all cutleries, pots, and pans to be in good repair. All appliances were fully functioning and in good repair. All sharps are secured in a locked drawer in the kitchen. All toxins are kept separate and secured in a locked cabinet under the sink. LPA observed an additional supply of cleaning products and toxins secured in the garage in a locked cabinet and inaccessible to residents. The water temperature measured 118.3-degrees Fahrenheit.

Common Rooms LPA observed all common rooms to have ample furniture to accommodate all residents. The living room has 2 couches and an aquarium. The family room has multiple single recliner chairs to accommodate all residents and visitors. The dining room has a large enough table and ample seating to accommodate all residents. LPA observed all hallways and walkways to be clean, clear, and free of obstructions and hazards. All rooms and walkways have ample lighting. The facility maintained a comfortable temperature. LPA observed the facility to be clean and sanitary at the time of visit.

Safety All smoke detectors were tested and are fully operational. Carbon Monoxide detector is fully operational. LPA observed 2 fully charged fire extinguishers, 1 mounted in the dining room and the other in the family room, last serviced on 06/09/22. The last emergency drill was conducted on 02/04/23. LPA inspected the First Aid Kit and found it to contain the required items and a manual. LPA observed all required posting throughout the facility, including but not limited to personal rights, complaint information, nondiscrimination notice, facility sketch, and Emergency & Disaster Plan. There are no firearms or ammunition stored on the premises.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2023

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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: PARADISE PALACE 11	FACILITY NUMBER: 198600693
	VISIT DATE: 03/13/2023

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Infection Control During the tour, LPA observed the facility’s infection control practices. LPA was properly screened for Covid-19 symptoms and temperature was checked. LPA observed a sanitizing station at the facility entrance; visitors log with Covid-19 screening and temperature log, and records of daily Covid-19 screening and temperature checks of residents and staff. PPE supplies are readily available to staff, and an additional 60+ day supply of PPE was observed stored in the garage. Sufficient paper, cleaning, and disinfecting supplies were observed. LPA observed staff wear a face covering. LPA observed all required infection control postings throughout the facility.

Medications LPA reviewed medications for all residents and matched them to the MARs. All medications are stored in a secured, locked cabinet in the dining room.

Files LPA reviewed all resident’s files and found they contain the required documentation. LPA reviewed 5 staff files and found they contained the required documentation, training, and certification. LPA interviewed 3 staff that were present during the visit. All 3 residents are nonverbal, LPA attempted interviews. LPA reviewed the facilities Surety Bond through News Financial & Insurance Services INC valid till 10/04/25. LPA reviewed all resident’s P&I.

No deficiencies were observed or cited during this visit.

An exit interview was conducted. A copy of this report was provided to Administrator, Janice Lofton.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2023

LIC809 (FAS) - (06/04)

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