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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603353
Report Date: 09/29/2022
Date Signed: 09/29/2022 12:13:00 PM

Document Has Been Signed on 09/29/2022 12:13 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:BELSHIRE PARAISOFACILITY NUMBER:
198603353
ADMINISTRATOR:ONG, JOHN CHRISTOPHERFACILITY TYPE:
735
ADDRESS:17807 BELSHIRE AVETELEPHONE:
(562) 402-6422
CITY:ARTESIASTATE: CAZIP CODE:
90701
CAPACITY: 4CENSUS: 3DATE:
09/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:John Christopher Ong (Administrator)TIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced annual visit at the facility with focus on the infection control domain, medication and food review. LPA Mora met with John Christopher Ong (Administrator) and explained the reason for the visit. The facility is licensed to serve four non-ambulatory clients ages 18-59, of which 2 may be bedridden. The facility currently has 1 ambulatory client (within age range) and 2 non-ambulatory clients (above the age range) which exceeds the 50% age acceptance or retention limit (refer to 85068.4(g)). However, the administrator has communicated with CCLD prior to this visit and requested an age exception. The age exception request is still pending. Administrator does not wish to change the facility from an Adult Residential Facility (ARF) to a Residential Care Facilities for the Elderly (RCFE).

A tour of the single-story facility included the following: family area, living room, dining area, kitchen, laundry area, 4 client bedrooms, 2 client bathrooms, front yard, backyard, and attached garage. LPA Mora conducted the tour with John Christopher Ong and observed the following: sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables were observed in the kitchen. Sharps were observed locked in a kitchen cabinet. Chemical and cleaning solutions are kept locked under the sink. The First Aid kit is kept locked in the medication cabinet and it is fully stocked with all required items including a current manual. Clean towels and extra clean linen were observed in the garage. Dining and living room have sufficient lighting and sitting area. Medications are kept locked in a dining area cabinet. Client and staff files are kept locked in a dining area cabinet. All bedrooms have all required furniture, lighting, and bedding. The client bathrooms were observed with shower mats. The water temperature was tested in all bathrooms and measured at 108.7 degrees F which is within the required 105-120 degrees F. A fire extinguisher was observed in the dining area and it is fully charged. Smoke detectors and carbon monoxides were observed throughout the facility and were operable during the visit. The front yard and backyard are clean. There is a shaded area with seating in the backyard. No bodies of water were observed at the facility. Passageways and exits are free of obstructions. (CONTINUED TO LIC 809C)
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2022
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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: BELSHIRE PARAISO
FACILITY NUMBER: 198603353
VISIT DATE: 09/29/2022
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LPA reviewed medication for 3 clients and observed that medications are documented properly and given as prescribed. LPA reviewed files for 3 clients and 4 staff. No issues were found with the files. LPA observed administrator certificate for John Christopher Ong – 6033089735 with an expiration date of 05/31/2023.

Facility has 30 days supplies of Personal Protective Equipment in the garage. Facility is following COVID-19 recommendations regarding screening visitors, staff, and clients. Covid-19 prevention signs are posted throughout the facility and hand-washing signs were observed in the bathrooms. Sufficient hand soap, hand sanitizer, and paper towels were observed.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there was no deficiencies observed during the visit. Exit interview held and a copy of the report was provided.

SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022
LIC809 (FAS) - (06/04)
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