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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004648
Report Date: 04/29/2022
Date Signed: 04/29/2022 04:07:29 PM


Document Has Been Signed on 04/29/2022 04:07 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 FOR THE ELDERLY #1FACILITY NUMBER:
306004648
ADMINISTRATOR:RENU MADAHARFACILITY TYPE:
740
ADDRESS:525 N. CAROUSEL PL.TELEPHONE:
(657) 208-3199
CITY:ANAHEIMSTATE: CAZIP CODE:
92806
CAPACITY:6CENSUS: 6DATE:
04/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Azeb Gebregziabher, caregiver
Renu Madahar, Administrator
Sunita Chand, Adminstrator		TIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility in order to conduct a required annual inspection. LPA arrived at facility, was greeted and granted entry by Azeb Gebregziabher, caregiver, after explaining the purpose of the visit and being screened for COVID-19. Administrator Renu Madahar was notified of the visit via phone call arrived later to assist with the visit.

At approximately 2:45pm, LPA accompanied by caregiver toured the inside and outside of the facility. There are currently six (6) residents in care, four (4) of which are stated to be on hospice. A fifth resident is scheduled to be admitted on hospice. Current waiver on file appears to be for a maximum capacity of four (4) residents on hospice so an updated waiver or a new request for increased capacity will have to be submitted ahead of the scheduled admission. The residents are observed to be relaxing in their bedrooms or in the common areas and appears well taken care of. The bedrooms include all necessary components. Bathrooms are equipped with grab bars and slip mats. Hand washing signs are being displayed. Facility appears to be clean and sanitary in all areas inspected. Staff present is observed to be correctly associated in Guardian.

Sharp instruments are kept in a cabinet secured by a magnetic lock, as are the cleaning supplies present in the kitchen. LPA observed the facility has COVID-19 Precautions posters and required department postings, however the Administrator certification posted are currently out of date. Administrator Renu Madahar was able to provide up-to-date versions during the visit.

Facility has an adequate supply of PPE. The LIC808 Mitigation Plan has been submitted. LPA has informed administrator that a new Infection Control document has been released and will have to be submitted to Licensing by 06/30/2022.

CONTINUED ON FORM LIC809-C
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2022
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 4


Document Has Been Signed on 04/29/2022 04:07 PM - It Cannot Be Edited

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 FOR THE ELDERLY #1
FACILITY NUMBER: 306004648

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4


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 FOR THE ELDERLY #1
FACILITY NUMBER: 306004648
VISIT DATE: 04/29/2022
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CONTINUED FROM FORM LIC809

LPA observed a sufficient supply of food and water. A 30-day supply of medication is centrally stored and locked in a cabinet. LPA toured the outside of the facility. The exterior of the facility is free of debris and obstruction, with a shaded area where outdoor furniture is located for the residents' and visitors' enjoyment, as well as storage areas and the caregiver's room. The perimeter gates are self-latching and can easily be opened in an evacuation.

Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations and a Technical Advisory is issued in regards to the mandatory postings being out of date as well as detergent not being locked. This report was reviewed with facility representative and a copy of this report was provided and left at facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4