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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004565
Report Date: 10/31/2024
Date Signed: 10/31/2024 03:20:56 PM

Document Has Been Signed on 10/31/2024 03:20 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:PARADISE RESIDENTIAL SENIOR CARE 3FACILITY NUMBER:
306004565
ADMINISTRATOR/
DIRECTOR:		ROSA ANGELINA REYESFACILITY TYPE:
740
ADDRESS:25676 MINOA DRIVETELEPHONE:
(949) 716-3699
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 4TOTAL ENROLLED CHILDREN: 0CENSUS: 3DATE:
10/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:00 AM
MET WITH:Rosa Angelina Reyes & Johan Matheus- AdministratorsTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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On October 31, 2024, Jessica Cho, Licensing Program Analyst (LPA) and Eboni Bentley Licensing Program Analyst (LPA) arrived at the facility unannounced for the purpose of conducting the Required 1-Year annual evaluation using the CARE Inspection Tool. LPAs met with Administrators Rosa Angelina Reyes and Johan Matheus and explained the reason for the visit. Certification for the administrators were verified during the visit.

The facility is a two story structure located in a residential neighborhood. Facility is licensed to operate for four (4) non-ambulatory and maintains a hospice waiver for four (4). There are three residents in care during today's visit of which one is in hospice. Two caregivers are on duty during the visit.

LPA observed the facility to be clean and sanitary. There are two resident bedrooms and one resident bathroom on the first floor. The second floor consists of three staff bedrooms, an office, and two bathrooms which are only utilized by two staff and administrator. All common areas were inspected including the attached two car garage. The residents' bedrooms were appropriately furnished. Beds and bedding supplies were in good condition, adequate lighting was provided, sufficient storage space for personal belongings were observed. Bathrooms were found to be in compliance, clean, and operational. The water temperature measured at 113.5 degrees Fahrenheit. Toxins, disinfectants, sharps, and medications were secured and inaccessible. LPAs observed sufficient two-day supply of perishables and seven-day supply of non-perishable food. The fireplace has a screen and is secure. LPAs toured the exterior portion of the facility. LPAs observed the outdoor passageway free of obstruction. The exit gate was self-closing and self-latching. The pool was gated and self-latching. LPAs observed sufficient seating and shading. Facility maintains two fire extinguishers one on each floor. Both were charged and serviced on July 1, 2024. The auditory devices and smoke/carbon monoxide detectors were tested and operational on both floors.
Lourdes MontoyaTELEPHONE: (714) -70-2870
Jessica ChoTELEPHONE: 714-703-2853
DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: PARADISE RESIDENTIAL SENIOR CARE 3
FACILITY NUMBER: 306004565
VISIT DATE: 10/31/2024
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LPAs observed the emergency disaster supplies including food/water in the garage. Emergency evacuation drills were conducted but not on a quarterly basis with the last drill conducted on April 2023. The first aid kit contains all necessary elements and is well maintained. LPAs observed the required 'See Something, Say Something' (PUB475) poster in the correct size.

LPA conducted an audit of three residents' files and two personnel files. No discrepancies were noted. Medications were audited for three residents. No discrepancies noted. Interviews were conducted with two staff and two residents on site.

Based on the observations made during today's visit, no deficiency is being cited today. A Technical Violation (TV) is being issued regarding evacuation drills.

An exit interview was conducted with Administrators Rosa Angelina Reyes and Johan Matheus, and a copy of this report was provided at the end of the visit.
SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024
LIC809 (FAS) - (06/04)
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