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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004656
Report Date: 06/14/2022
Date Signed: 06/15/2022 08:26:13 AM

Document Has Been Signed on 06/15/2022 08:26 AM - 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:WELSH GATEFACILITY NUMBER:
306004656
ADMINISTRATOR:PAUL SHAHPARAKIFACILITY TYPE:
735
ADDRESS:3201 ORANGEWOOD AVENUETELEPHONE:
(562) 598-9051
CITY:ROSSMOORSTATE: CAZIP CODE:
90720
CAPACITY: 4CENSUS: 2DATE:
06/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Licensee Paul ShahparakiTIME COMPLETED:
04:35 PM
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Licensing Program Analyst (LPA) Shobhana Frank made an unannounced visit to the facility for the purpose of conducting an required 1 year inspection. LPA met with Licensee Paul Shahparaki. Licensee Paul Shahparaki accompanied LPA on the inspection of the physical plants interior and exterior. LPA Frank toured the facility. The facility is an existing licensed ARF approved for 4 residents. There are 2 resident resides at this facility. At the time of the inspection the were visiting their parents. Facility is a 4 bedroom, 3 bathroom, single story house. LPA observed COVID - visitation station equipped with hand sanitizer, thermometer, visitors log. LPA observed COVID posters throughout the facility.
LPA observed required department postings in the facility as well as hand washing signs in the restrooms. All restrooms observed had ample soap/ sanitizer and appeared clean. Resident bedrooms appeared clean and sanitary and had all required components.
LPA observed the emergency disaster and evacuation plans. Facility has back-up emergency food and water supply as well as PPE supplies. In addition, LPA Frank tested the hot water temperature, which measured 110.2 degrees F in resident
bathroom. Resident areas were noted to be a comfortable temperature. The facility also has fire extinguisher that was mounted and charged. LPA Frank confirmed food supply: 2 day supply of perishables and 7 day supply of non-perishable food is available for the number of residents present. Hygiene supplies and supply of linen were observed in quantities for the number of residents in care. LPA observed locked areas for toxins and hazardous items. Medication were observed locked in cabinet.
LPA Frank reviewed : 1.) Emergency Disaster Plan (LIC610E); 2 ) LIC 9020A Client Roster; LIC 808)
Mitigation Plan and 3) Current Liability Insurance, Designation of Administrative Responsibility (LIC308) and
Personnel Report (LIC500);
Based on the observations made during today’s visit, no deficiencies are being cited in area inspected.
This report was discussed with the facility representative and a copy was provided.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Shobhana Frank
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2022
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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