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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006014
Report Date: 07/15/2022
Date Signed: 07/15/2022 12:23:54 PM


Document Has Been Signed on 07/15/2022 12:23 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:RAYA'S PARADISE OF SAN CLEMENTEFACILITY NUMBER:
306006014
ADMINISTRATOR:WESTPHALN, MONICAFACILITY TYPE:
740
ADDRESS:101 AVENIDA CALAFIATELEPHONE:
(949) 420-9898
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92672
CAPACITY:80CENSUS: DATE:
07/15/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Moti Gamburd, Monica Westphaln, and David AlvaradoTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Kimberly Lyman made an announced visit to conduct a pre-licensing inspection. LPA identified herself and discussed the purpose of the visit with Facility Owner Moti Gamburd. An initial application to operate a Residential Care Facility for the Elderly was received by Community Care Licensing on 10/25/2021 for a capacity of eighty bedridden residents. Facility utilizes an electronic sign in sheet/ health questionnaire and LPA was screened upon entry.
LPA Lyman along with Facility Owner Moti Gamburd, Executive Directors Monica Westphaln and David Alvarado as well as Maintenance Director Gilbert Buenrosto toured the facility at 9:08 AM. Contractor Jeff Shell joined the tour in progress. The following was observed during the tour:
Structure: Facility is a three story building with a deck on the third floor and a basement. Facility consists of a 20 bed memory care unit and assisted living. LPA observed a beauty salon, gym, and multiple lounges for relaxing and activities. There are multiple outside areas for visitation. Common Areas: Adequate seating is available in common areas on each floor. Bedrooms Clients: Rooms will be single and double occupancy. All memory care rooms are equipped with appropriate lighting, chair, night stand and ample closet space. Assisted living residents to provide their own furnishings or select from facility offerings. LPA observed the model room with furnishing choices. Bathrooms: All resident bathrooms have a working toilet/ wash basin as well as non-skid surface in the shower and grab bars. Linens & Hygiene Supplies: Facility has bedding, towels and hygiene supplies for residents in care. Emergency Phone Numbers and Exit Plan: Posted in facility. Facility has ample PPE supply present. Food Service: Facility has 2 day perishables as well as 7 day non-perishables. LPA observed ample emergency food and water. Smoke Detectors: Smoke detectors/ carbon monoxide detectors are centrally wired and serviced by Symons Fire Protection. Fire extinguishers are mounted and charged. Appliances: LPA observed kitchen area as well as two laundry facilities. All items are clean and operational. Toxins/ Sharps: Facility has secured areas for toxins. Water Temperature: Tested and recorded between 105 and 113 degrees F. in facility restrooms. CONTINUED ON LIC 809C DATED 07/15/2022
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2022
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: RAYA'S PARADISE OF SAN CLEMENTE
FACILITY NUMBER: 306006014
VISIT DATE: 07/15/2022
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Medications, First-Aid Kit & Book: First aid kit observed contained all required items. Medication to be stored and locked in secured Wellness station. Facility uses an electronic medication administration record. Client & Staff File: Resident records to be stored electronically and hard copy in the Wellness station. Staff files are secured in an office in the basement. Reading Material, Games, and Equipment: Facility has an electronic activity schedule in the facility. Activities to include yoga, games, arts and outings in the community. Fire Clearance: Approved for 80 bedridden residents on 06/29/2022.




Component III waived during visit. Licensee is a current operator of another facility.
Facility is ready to licensed.


Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2022
LIC809 (FAS) - (06/04)
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