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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004565
Report Date: 10/04/2022
Date Signed: 10/04/2022 01:06:15 PM


Document Has Been Signed on 10/04/2022 01:06 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 3FACILITY NUMBER:
306004565
ADMINISTRATOR:ROSA ANGELINA REYESFACILITY TYPE:
740
ADDRESS:25676 MINOA DRIVETELEPHONE:
(949) 716-3699
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:4CENSUS: 3DATE:
10/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:52 AM
MET WITH:Johan MathewsTIME COMPLETED:
01:15 PM
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On 10/04/2022 at 11:52am, Licensing Program Analyst (LPA) Jessica Cho conducted an unannounced visit to Paradise Residential Senior Care 3. The purpose of today's visit was to conduct a Required 1 Year visit focusing primarily on the Infection Control. At 11:55am, LPA Cho was allowed entry in the facility and met with Caregiver Marina Zuniga after completing the Coronavirus 2019 (COVID-19) screening procedure. Administrator (Admin) Johan Mathews arrived at the facility at 12:04pm followed by Licensee/Administrator (Admin) Rosa Angelina Reyes. As of today, there are no active COVID-19 cases in the facility. Facility screens and documents temperatures for all visitors on a sign in sheet as well as residents. LPA observed the required COVID-19 precautionary signs posted on the front door and throughout the facility. The Complaint Poster (PUB475) met the Department's size requirements. The facility is licensed for four non-ambulatory residents and has a Hospice waiver for four. There are currently three residents living in the facility of which three are receiving hospice care.

At 12:06pm, LPA Cho conducted a tour of the physical plant along with Admin Mathews. The two story home consists of two resident bedrooms with one resident bathroom. There is one staff bedroom and two full bathrooms on the second floor. The facility also has a living room, family room, formal dining room, dining area, kitchen, and an attached two car garage on the first floor. On the second floor there is an office, a master bedroom, and a room utilized as storage. The resident bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each resident comfortably. Resident bathroom was checked. The toilet and water faucet worked properly, grab bar was secure, the shower was free of mold/mildew, and a non-skid surface or mat was in place. Resident bath towels and personal hygiene supplies were adequately stocked including paper towels and hand soaps. LPA Cho tested the hot water temperature in the resident bathrooms and the temperature measured at 117.1 degrees Fahrenheit.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2022
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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: PARADISE RESIDENTIAL SENIOR CARE 3
FACILITY NUMBER: 306004565
VISIT DATE: 10/04/2022
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LPA Cho inspected the kitchen along with Admin Mathews. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. The fire extinguisher was fully charged and was last serviced on July 6, 2022. The smoke and carbon monoxide detectors were tested and operational. Medications, toxins, and sharps were locked and inaccessible to the residents. The auditory alarms throughout the facility were in operating condition.

LPA Cho along with Admin Mathews toured the outside grounds. A swimming pool was observed, and the gate was locked. There was a shed that was locked which stored gardening supplies and tools. There was shading and sufficient seating for residents. Walkways around the home were clear of hazards, and the exit gate was self-closing and self-latching.

LPA Cho reviewed the Emergency and Disaster Plan for Residential Care Facilities for the Elderly (LIC610E). Facility has a plan for COVID-19 testing residents and staff as well as a plan for isolation as needed. Facility has back-up emergency food and water supply. The First Aid Kit had all the required components, and the facility had sufficient PPEs.

No resident or staff files were reviewed at the time of this visit. LPA Cho reviewed Assembly Bill 665. This bill would require residential facilities serving adults, residential care facilities for persons with chronic life-threatening illness, and residential care facilities for the elderly with existing internet service to provide at least one internet access device that can support real-time interactive applications, is equipped with video conferencing technology, and is dedicated for client or resident use. The facility does have an existing internet service and provides the residents a facility smart phone upon request. Amin Mathews was reminded of the importance of staying abreast with CCLD’s COVID-19 guidance and additional information by reviewing and printing the Provider Information Notices (PINs) as well as by attending the CCLD Informational Calls. The PINs can be accessed at: www.ccld.ca.gov.

Based on the observations made during today's visit, no deficiency is cited in this review as per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Administrator Johan Mathews and Licensee/Administrator Rosa Angelica Reyes, and a copy of this report was provided.

SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2022
LIC809 (FAS) - (06/04)
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