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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603353
Report Date: 09/11/2025
Date Signed: 09/11/2025 12:09:29 PM

Document Has Been Signed on 09/11/2025 12:09 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:BELSHIRE PARAISOFACILITY NUMBER:
198603353
ADMINISTRATOR/
DIRECTOR:		ONG, JOHN CHRISTOPHERFACILITY TYPE:
735
ADDRESS:17807 BELSHIRE AVETELEPHONE:
(562) 402-6422
CITY:ARTESIASTATE: CAZIP CODE:
90701
CAPACITY: 4CENSUS: 4DATE:
09/11/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:John Christopher Ong, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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Licensing Program Analysts (LPAs) Daniel Konishi and Gabriela Castro conducted the required unannounced annual inspection. LPAs met with Nanzi Martinon, Caregiver who contacted the Administrator, John Christopher Ong. The administrator arrived and LPAs explained the reason for the visit. This home is licensed to serve the age range 18 through 59. Approved for (4) non-Ambulatory of which (2) may be bedridden.

LPAs utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting clients’ medications. Staff are cleaning and disinfecting throughout the day. The facility has sufficient PPE supplies and has an Infection Control Plan maintained at the facility.

Physical Plant & Environment Safety: This home contains 4 bedrooms, 2 bathrooms, living room/Lobby, Family area, kitchen, dining room, laundry room and an attached garage. LPAs toured the physical plant and observed all (4) client bedrooms, contained required furniture, lamps, dresser, chair, and closet space. The bed and furnishings were all in good working condition. The two bathrooms contain a working toilet, basin, and water faucet, walk in shower with grab bar, shower chair, and bathmat. LPAs measured the hot water temperature at 107.9 degrees F and 108.0 degrees F which are within 105 degrees F and 120 degrees F Title 22 regulations. Carbon Monoxide detectors were tested and working properly. The knives were secured and locked in a kitchen cabinet. The toxin and cleaning supplies was locked underneath the kitchen sink. Extra Linens and towels are in each clients’ bedroom. There were (2) fire extinguishers located in the family area and the dining room was fully charged and last inspected on 07/03/2025. Walls and floors, cabinets and counters were clean and sanitary throughout the home.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: BELSHIRE PARAISO
FACILITY NUMBER: 198603353
VISIT DATE: 09/11/2025
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Physical Plant & Environment Safety [Cont.]: 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 storage supplies, PPE supplies, cleaning supplies, emergency food and toiletries.

Operational Requirements: Staff have proper training to meet the needs of the clients in care. The facility has an activity area furnished for outdoor use. Last fire/earthquake drill was conducted on 08/22/2025. The facility has a valid Liability Insurance in place.

Staffing: There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in the care and supervision of the clients in case of an emergency.

Personnel Records-Training: Staff files are maintained in a secure location. LPAs reviewed four (4) staff files that includes the Personnel Record, Criminal Background Clearance, Health Screening, TB Clearance, Valid First-Aid, Employee Rights, and sufficient on-going training. The administrator maintains a valid certificate that expires on 05/31/2027. However, LPAs reviewed staff records and the Administrator does not have updated HIV and TB training in file.

Client Rights-Information: Facility provides telephone lines and internet for the clients. Client rights posters and reporting posters are displayed within the facility.

Food Service: LPAs toured the kitchen which appeared clean and the appliances and fixtures functional. The facility kitchen was observed to be clean at the time of inspection. There are sufficient food supplies of 2-day perishable and 7-day non-perishable items. The food is properly stored in the refrigerator. Per administrator, there are no clients with modified diets residing at this facility. Plates, cups and utensils are kept clean and stored properly.

Client Records-Incident Reports: Client files are maintained in a secure locked cabinet. LPAs reviewed four (4) client files which includes the Identification and Emergency Information, Admission Agreement, Physician's Report, Ambulatory Status, TB Clearance, Pre-Placement Appraisal, Personal Rights, and the Appraisal / Needs and Services Plan.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2025
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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: BELSHIRE PARAISO
FACILITY NUMBER: 198603353
VISIT DATE: 09/11/2025
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Health Related Service: Staff designated to administer medication have the proper annual training on file. Medication is properly labeled and are centrally stored in a locked cabinet and are in their original containers. LPAs reviewed four (4) client’s medications with no issues.

Incidental Medical & Dental: All training is documented in the facility personnel files. Staff performance is reviewed annually, and documentation is maintained in the personnel files. Per the Administrator, no clients at this home has an restricted health condition. Half bed rails for mobility assistance were observed in some client rooms and LPA reviewed clients’ files with half bed rail orders.

Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least two (2) relocation sites. The facility maintains documentation of the required emergency drills. The last fire/earthquake drill was conducted on 08/22//2025.

Emergency Intervention: Clients at this facility do not need the use of restraints or seclusion.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809-D. Exit interview, appeals rights and a copy of this report were provided to the Administrator, John Christopher Ong.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/11/2025 12:09 PM - It Cannot Be Edited


Created By: Daniel Konishi On 09/11/2025 at 11:57 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BELSHIRE PARAISO
FACILITY NUMBER: 198603353

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064(k)
Administrator Qualifications and Duties
(k) Within six months of becoming an administrator, the individual shall receive training on HIV and TB required by Health and Safety Code Section 1562.5. Thereafter, the administrator shall receive updated training every two years.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, LPAs observed that the Administrator does not have an updated HIV and TB training in file.which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/25/2025
Plan of Correction
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Administrator will sent the updated HIV and TB training to the LPA by the POC due date.
Daniel.Konishi@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Daniel Konishi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2025


LIC809 (FAS) - (06/04)
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