306006014-8-27-2024-22-AS-KLYN-D8HUKG-20240826153907

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006014
Report Date: 08/26/2024
Date Signed: 08/27/2024 07:03:36 AM

Document Has Been Signed on 08/27/2024 07:03 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:	RAYA'S PARADISE OF SAN CLEMENTE		FACILITY NUMBER:	306006014
ADMINISTRATOR:	WESTPHALN, MONICA		FACILITY TYPE:	740
ADDRESS:	101 AVENIDA CALAFIA		TELEPHONE:	(949) 420-9898
CITY:	SAN CLEMENTE	STATE: CA	ZIP CODE:	92672
CAPACITY:	80	CENSUS: 37	DATE:	08/26/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:22 AM
MET WITH:	Monica Westphaln		TIME COMPLETED:	04:00 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	Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit to Raya's Paradise of San Clemente. The purpose of today’s visit was to conduct the Annual Required inspection. LPA was allowed entry into the facility and explained the reason for the visit. Facility is licensed for 80 bedridden residents. Facility has an approved hospice waiver for 40 residents and the facility currently has 4 residents on hospice care. Administrator Monica Westphaln has an administrator certificate valid until 11/08/2024. LPA Lyman along with Chief Operating Officer/ Executive Director Monica Wetsphaln and Maintenance Director Gilbert Buenrostro toured the facility at 11:45 AM. LPA toured the physical plant, checked food service, first aid kit and reviewed records. Facility appears to be clean, safe, and sanitary. The facility consists of three stories housing an assisted living, memory care, gym, salon and multiple ouside patios. Resident apartments had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. LPA observed three residents with a half bed rails. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 106.0 and 110.10 degrees F in all facility bathrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. Delayed egress doors in memory care are operational. Facility has multiple first aid kits with all the elements including thermometer, tweezers and scissors. LPA observed no unsecured toxins during today's visit. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Facility refrigerators and freezers are monitored and within temperature guidelines. LPA observed two dining rooms serving residents. Smoke detectors and Carbon Monoxide detectors are tested by an outside company with the last inspection conducted on 07/05/2024. Fire extinguishers are fully charged. LPA toured the outside grounds and there is ample shaded seating for residents in multiple patios. LPA observed ample emergency food and water supply. LPA reviewed the emergency disaster plan during the visit. Plan is thorough and complete. Facility provided documentation of last fire drill conducted on 07/16/2024. CONT ON LIC809-C DATED 08/26/2024.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024

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: 08/26/2024

NARRATIVE

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Facility provides activities in the form of exercise, games, music and outings in the community. LPA reviewed select resident and staff files. Resident files contained required documents including admission agreements, physician reports, resident appraisals and orders for bed rails as indicated. Staff files reviewed contained required documentation of medical clearance/ TB, CPR training and criminal record clearance. LPA reviewed medication storage and administration. Medications are stored in a locked medication cart. Medications are being administered per physician order.

Based on the observations made during today's visit, NO citations are being issued. Exit interview conducted and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024

LIC809 (FAS) - (06/04)

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