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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600693
Report Date: 03/08/2024
Date Signed: 03/08/2024 04:06:36 PM

Document Has Been Signed on 03/08/2024 04:06 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:PARADISE PALACE 11FACILITY NUMBER:
198600693
ADMINISTRATOR:LOFTON, JANICEFACILITY TYPE:
735
ADDRESS:5134 W 136TH STTELEPHONE:
(310) 355-5997
CITY:HAWTHORNESTATE: CAZIP CODE:
90250
CAPACITY: 3CENSUS: 3DATE:
03/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Administrator, Janice LoftonTIME COMPLETED:
04:15 PM
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On 03/08/2024 at 130 pm Licensing Program Analyst (LPA) David España conducted an unannounced 1-year Annual Inspection using the full CARE tools. The purpose of today’s visit was discussed. Upon arrival at the facility, LPA España conducted a risk assessment at the front door. Based on the assessment, the facility is clear of Covid-19 infection. LPA España was granted access and allowed to enter the facility to conduct inspections. During today’s visit we were joined by Administrator, Janice Lofton and Detrice Johnson, House Manager/DSP. 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. 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. LPA España 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 España did not observe any bodies of water on the premises. Continued LIC 9099-C
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2024
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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: PARADISE PALACE 11
FACILITY NUMBER: 198600693
VISIT DATE: 03/08/2024
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 All walkways are clean, clear, and free of obstructions, debris, or hazards.
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 España 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. LPA España 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 España 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. 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 España observed a shower chair and a nonskid mat. LPA España observed an ample supply of hygiene products for residents. The water temperate in the bathrooms measured between 115 degrees and 116 degrees Fahrenheit. LPA España 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 España 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 España 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 117 degrees Fahrenheit. Continued LIC 9099-C

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024
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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: PARADISE PALACE 11
FACILITY NUMBER: 198600693
VISIT DATE: 03/08/2024
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LPA España observed all common rooms to have ample furniture to accommodate all residents. The living room has Two (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 España 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 España observed the facility to be clean and sanitary at the time of visit. All smoke detectors were tested and are fully operational. Carbon Monoxide detector is fully operational. LPA España observed Two (2) fully charged fire extinguishers, 1 mounted in the dining room and the other in the family room, last serviced on May 10, 2023. The last emergency drill was conducted on 12/09/2023. LPA España inspected the First Aid Kit and found it to contain the required items and a manual. LPA España 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. LPA España reviewed medications for all residents and matched them to the MARs. All medications are stored in a secured, locked cabinet in the dining room. LPA España reviewed all resident’s files and found they contain the required documentation. LPA España reviewed Five (5) staff files and found they contained the required documentation, training, and certification. LPA España interviewed Three (3) staff that were present during the visit. All Three (3) clients are nonverbal, LPA España attempted interviews. Continued LIC 9099-C
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024
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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: PARADISE PALACE 11
FACILITY NUMBER: 198600693
VISIT DATE: 03/08/2024
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 LPA España reviewed the facilities Surety Bond through News Financial & Insurance Services INC valid till 10/04/2025. LPA España 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: Ulysses Coronel
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024
LIC809 (FAS) - (06/04)
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