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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004382
Report Date: 02/28/2024
Date Signed: 02/28/2024 12:43:32 PM


Document Has Been Signed on 02/28/2024 12:43 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:PARADISE RESIDENTIAL SENIOR CARE 2FACILITY NUMBER:
306004382
ADMINISTRATOR:ROSA A. REYESFACILITY TYPE:
740
ADDRESS:24262 TWIG STREETTELEPHONE:
(949) 588-8951
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY:6CENSUS: 6DATE:
02/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Alex Matthews and Diana ManzanoTIME COMPLETED:
01:05 PM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit to Paradise Residential Senior Care 2. The purpose of today’s visit was to conduct the Annual Required inspection. LPA was allowed entry into the home and met with Caregiver Israel Arce. Facility is licensed for 6 non-ambulatory residents with hospice waiver for 6. Facility has 6 residents with 1 on hospice care. Rosa Reyes has an Administrator Certificate expiring on 04/11/2024. Administrators Alex Matthews, Diana Manzano and Rosa Reyes arrived during the visit.

LPA Lyman along with Administrators toured the facility at 9:54 AM. LPA toured the physical plant, checked food service, and the first aid kit. The home consists of five resident bedrooms, one resident bathroom, one staff room, one shared hall bathroom, living room, dining room, and kitchen. Facility has a second story with no current occupants. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. LPA observed two residents with a half bed rails. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 108.9 and 119.3 degrees F in all facility bathrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Resident hygiene supplies are locked and inaccessible to residents. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including tweezers, thermometer, and scissors. During today's visit, auditory door alarms are operational. LPA observed cleaning supplies/ toxins are secured. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed sharps locked in a kitchen drawer. Smoke detectors and Carbon Monoxide detectors are hardwired and tested operational during today's visit. Fire extinguishers are fully charged. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample shaded seating for residents. LPA observed emergency food and water supply in the garage. LPA reviewed the emergency disaster plan as well as the infection control plan during the visit. Plans are thorough and complete. Facility provided documentation of last fire drill conducted on 12/01/2023. Facility provides activities in the form of exercise. CONTINUED ON 809C DATED 02/28/2024

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2024
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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: PARADISE RESIDENTIAL SENIOR CARE 2
FACILITY NUMBER: 306004382
VISIT DATE: 02/28/2024
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At 10:35 AM, LPA reviewed six resident files and three staff files. Resident files contained required documents including admission agreements, current physician reports, resident appraisals and orders for half bed rails as indicated. Staff files reviewed contained required documentation of annual training, health screen/TB, and criminal record clearance. At 11:20 AM, LPA reviewed medication storage and administration. Medications are stored in a locked closet and are audited monthly by staff. Medications are being administered per physician order.

Based on the observations made during today's visit, no deficiencies are being cited.
Exit interview conducted and a copy of this report was given at time of visit.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2024
LIC809 (FAS) - (06/04)
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