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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004678
Report Date: 08/03/2022
Date Signed: 08/03/2022 04:27:48 PM


Document Has Been Signed on 08/03/2022 04:27 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 4FACILITY NUMBER:
306004678
ADMINISTRATOR:ROSA ANGELICA REYESFACILITY TYPE:
740
ADDRESS:24102 ADONIS STREETTELEPHONE:
(949) 305-9966
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: DATE:
08/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:39 PM
MET WITH:Rosa Angelica Reyes, Diana Manzano, Johan MathewsTIME COMPLETED:
04:45 PM
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On 08/03/2022, Licensing Program Analyst (LPA) Jessica Cho conducted an unannounced visit to Paradise Residential Senior Care 4. The purpose of today's visit was to conduct a Required 1 Year visit focusing primarily on Infection Control. At 2:48pm, LPA Cho was allowed entry in the facility and met with Caregiver Blanca Gonzalez after completing the Coronavirus 2019 (COVID-19) screening procedure. Caregiver Gerardo Contreras was also present at the facility. Administrator (Admin) Rosa Angelica Reyes entered the facility at 2:53pm and assisted with the tour. 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) was observed in the required Department sizing. The facility is licensed for six non-ambulatory residents and has a Hospice waiver for six. There are currently six residents living in the facility of which three are receiving hospice services.

At 2:54pm, LPA Cho conducted a tour of the physical plant along with Admin Reyes. The two story home consists of three resident bedrooms with two resident bathrooms. There are three staff bedrooms and two staff bathrooms on the second floor. The facility also has a living room, family room, dining area, kitchen, staff living room on the second floor, and an attached two car garage. The resident bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, showers were 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 119.3 degrees Fahrenheit in the Bathroom #1 and 118.5 degrees Fahrenheit in Bathroom #2.

LPA Cho inspected the kitchen along with Admin Reyes. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. The fire extinguisher was fully charged.

SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2022
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 3


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 4
FACILITY NUMBER: 306004678
VISIT DATE: 08/03/2022
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 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 Reyes toured the outside grounds. There were no bodies of water present. 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. There were no security bars or weapons on the premises.

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 not have an existing internet service, therefore the facility does not require to provide an internet access device.

At 3:20pm, Admin Diana Manzano entered the facility following Admin Johan Mathews who entered the facility at 3:34pm. Licensee Rosa Reyes left the facility due to personal reasons and LPA Cho conducted the exit interview with Admins Manzano. Amin Manzano 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: ccld.ca.gov.

LPA reviewed the COVID-19 mitigation plan of the facility. No deficiency cited in this review as per Title 22 Division 6 of the California Code of Regulations. An Advisory Note (LIC9102) was issued during the visit. Exit interview was conducted with Administrator Diana Manzano, 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: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022
LIC809 (FAS) - (06/04)
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