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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603353
Report Date: 09/12/2023
Date Signed: 09/12/2023 02:32:42 PM

Document Has Been Signed on 09/12/2023 02:32 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: 4DATE:
09/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator Christopher Ong TIME COMPLETED:
02:50 PM
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On 9/12/23 at 10:30 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced Annual/Required inspection to Belshire Paraiso. Upon arrival LPA was greeted by Direct Support Professional (DSP) Rolando Mallare who contacted the Administrator, Christopher Ong. The administrator arrived at 10:40 p.m. and LPA explained the reason for the visit. This home is licensed to serve age range 18 through 59. Approved for (4) non-Ambulatory of which (2) may be bedridden. There were (4) clients in care during the time of this visit. The last emergency disaster/fire drill was conducted on 9/09/23. The Administrator Certificate expires on 6/1/2021 # 6033089735. LPA checked the pending list and observed the Administrators name. During today's visit LPA inspected the physical plant inside and outside, reviewed the food supply, tested the smoke/carbon monoxide detectors, reviewed (3) staff files, (4) client files, medications, and medication administration records for (4) clients.

This home contains 4 bedrooms, 2 bathrooms, living room/Lobby, Family area, kitchen, dining room, laundry room and an attached garage. LPA toured the physical plant with the Administrator. and observed all (4) client bedrooms, contained required furniture, lamps, dresser, chair, and closet space. The two bathrooms contain a working toilet, basin and water faucet, walk in shower with grab bar, shower chair, and bathmat. The temperature measured at 106.5*F-106.7*F. The smoke detectors were battery operated and individually tested and observed to be working properly. The carbon monoxide detector was located throughout the facility, tested, and functioning properly. There were (2) fire extinguishers located in the family area and dining room fully charged and up to date. The kitchen was toured and contained working appliances; refrigerator, stove, oven and contained dishware, cups, plates, utensils, pots, and pans. The knives were secured and locked in a kitchen cabinet. The toxin and cleaning supplies was locked underneath kitchen sink. The pantry was well stocked with canned goods, pasta, cereals, and the food supply contained a sufficient supply with a two-day supply of perishables and a seven-day supply of non-perishables that met title 22 guidelines. Walls and floors, cabinets and counters were clean and sanitary throughout the home.
(Report continued on LIC809C.)
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2023
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: BELSHIRE PARAISO
FACILITY NUMBER: 198603353
VISIT DATE: 09/12/2023
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The outdoor grounds were toured and inspected, and the patio was well maintained with a shaded seating area accessible for client use and 2 sheds that contained storage supplies. The garage contained a storage supplies, PPE supplies, cleaning supplies, emergency food and toiletries.

Exit interview conducted with Christopher Ong, Administrator, a copy of this report was provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023
LIC809 (FAS) - (06/04)
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