<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004648
Report Date: 04/17/2023
Date Signed: 04/17/2023 03:04:32 PM


Document Has Been Signed on 04/17/2023 03:04 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 & INLAND A/SC, 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: 3DATE:
04/17/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Renu Madahar, AdministratorTIME COMPLETED:
02:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of documenting deficiencies observed during the initial investigation visit regarding complaint 22-AS-20230410115817.

LPA accompanied by caregiver toured the facility's physical plant. Two fire extinguishers are observed to be mounted on the walls of the common areas. Both maintenance tags observed show that the last maintenance was performed in August 2021, meaning the annual maintenance obligation has lapsed in August 2022, approximately eight months before the present visit. Facility administrator Renu Madahar states that a technician visit is planned for the day of the inspection, as the lapsed maintenance was pointed out by a member of a resident's family over the previous weekend. A type B citation is being issued.

For the purpose of investigating unrelated allegations, LPA conducted a review of the residents records maintained at the facility. The records for resident R1 include a physician report based on a visit dated May 27, 2021. Resident is stated to have a dementia diagnosis, which is associated with a yearly obligation to reassess the resident. Based on the deficiency observed, a second type B citation is being issued today.

Finally, the Guardian application for staff member S1 is observed to be incomplete. Staff member has been fingerprinted, but licensee and applicant were notified of a missing form LIC508 (Criminal Record Statement and Out-Of-State Disclosure) as part of the application. LPA provided a consultation on the topic with facility administrator and issued a Technical Assistance Advisory Note to that extent.

Finally, a consultation is provided on Reporting Requirements expectations from the Department.

An exit interview was conducted and a copy of this report along with appeal rights were provided and left to facility representative.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2023
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 2


Document Has Been Signed on 04/17/2023 03:04 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
ORANGE & INLAND A/SC, 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: 04/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/01/2023
Section Cited

1
2
3
4
5
6
7
The California Code of Regulations Section 87303(a) on Maintenance and Operation states that: " The facility shall be (...) safe, (...) and in good repair at all times. Maintenance shall include provision of maintenance services(...)." This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee is to schedule the required annual maintenance on both mounted fire extinguishers and provide documentation thereof to LPA before the Plan of Correction due date.
8
9
10
11
12
13
14
Based on observation conducted, the two mounted fire extinguishers were observed to have expired maintenance tags dated August 2022. This poses a potential risk to the health, safety and/or personal rights of individuals in care.
8
9
10
11
12
13
14
Type B
05/17/2023
Section Cited

1
2
3
4
5
6
7
The California Code of Regulations Section 87705(c)(5) Care of Persons with Dementia states that: "Each resident with dementia shall have an annual medical assessment (...), and a reappraisal done at least annually". This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee is to schedule a follow-up appointment with either the resident Primary Care Provider or with the Hospice Physician in order to obtain an updated Medical Assessment. Report to be provided to LPA before the Plan of Corrections due date.
8
9
10
11
12
13
14
Based on a review of resident records at the facility, the most recent physician report for resident R1 is dated May 27, 2021, and has been outdated for 11 months. This poses a potential risk to the health, safety and/or personal rights of individuals in care.
8
9
10
11
12
13
14
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: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2