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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336412274
Report Date: 07/09/2021
Date Signed: 07/09/2021 12:49:56 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:BIRD OF PARADISE ASSISTED LIVING IN TEMECULAFACILITY NUMBER:
336412274
ADMINISTRATOR:SUON, SARAKFACILITY TYPE:
740
ADDRESS:44754 PRIDE MOUNTAIN STTELEPHONE:
(951) 302-1335
CITY:TEMECULASTATE: CAZIP CODE:
92592
CAPACITY:6CENSUS: 0DATE:
07/09/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Sarak SuonTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Javier Prieto and LPA Anna Bueno conducted an announced visit for the purpose of following up on a voluntary closure of the facility. LPAs were met by licensee Sarak Suon and granted entry. LPAs toured the facility and confirmed that there are no longer residents in the home. LPAs observed the licensee was removing furnishings from the home. LPAs confirmed that all five rooms are empty, without any furniture.

Licensee has submitted to California Department of Social Services (Department) a letter of intent to close addressed to residents families dated June 28, 2021.
Licensee has submitted to the Department a letter of explanation for facility closure addressed to LPA Prieto dated July 7, 2021.
Licensee has voluntary surrendered the facility license to the Department Riverside regional office on July 6, 2021.

During time of inspection, LPAs noted deficiencies related to procedures when closing facility and reporting requirements related to the death of client while facility was in operation. Deficiencies are noted on LIC 809D.
An exit interview was conducted, and a copy of this report was reviewed with and provided to Sarak Suon
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021
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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BIRD OF PARADISE ASSISTED LIVING IN TEMECULA
FACILITY NUMBER: 336412274
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/09/2021
Section Cited

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(a) A licensee of a licensed residential care facility for the elderly shall, prior to transferring a resident of the facility to another facility or to an independent living arrangement as a result of forfeiture of a license...
(2) Provide each resident or the resident's responsible person with a written notice no
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later than 60 days before the intended eviction.
This section was not met as evidenced by:


Licensee submitted notice of facility closure dated June 28, 2021.
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Type B
07/09/2021
Section Cited

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REPORTING REQUIREMENTS
(a) Each licensee shal furnish to the licensing agency such reports...
(1) A written report shall be submitted to the licensing agency and to the person reposinsible for the resident within seven days of the occurrence...
(A) Death of any resident from any cause...
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This section was not met as evidenced by:


Licensee has submitted LIC624A, Death report, on 7/6/2021 for a resident death that occurred on 6/19/2021.
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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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:
DATE: 07/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2021
LIC809 (FAS) - (06/04)
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