361800177-10-28-2024-56-AS-MECA-DAGSHG-20241028135331

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361800177
Report Date: 10/28/2024
Date Signed: 10/28/2024 01:53:50 PM

Document Has Been Signed on 10/28/2024 01:53 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	PARADISE FOR THE ELDERLY #2		FACILITY NUMBER:	361800177
ADMINISTRATOR/ DIRECTOR:	MADAHAR, RENU		FACILITY TYPE:	740
ADDRESS:	8568 BAKER AVE		TELEPHONE:	(909) 463-8432
CITY:	RANCHO CUCAMONGA	STATE: CA	ZIP CODE:	91730
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	10/28/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:10 AM
MET WITH:	Faryal Khan-Staff		TIME VISIT/ INSPECTION COMPLETED:	02:06 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) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with Staff (Pending Licensee/Administrator), Faryal Khan and introduced self and stated purpose of the visit. LPA was informed that there are currently 6 residents in care who are in the facility. The facility has (6) resident bedrooms, (3) resident bathrooms, living room, dining area, kitchen, backyard, and attached garage. LPA completed a walk through of facility and review of records. Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 76 degrees fahrenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected resident bathrooms; bathrooms were clean and appliances were found functional. LPA observed grab bar missing from the toilet in one bathroom. Deficiency issued. LPA observed insufficient hygiene products for residents. Deficiency issued. Water temperatures tested at 115.7 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, fire extinguisher and first aid kit. Posters such as; the personal rights, ombudsman and emergency disaster plans were posted in a common area. There was a designated storage space for resident/staff files. Resident medications were observed secured and inaccessible to residents. LPA observed accessible staff's cough medicine in the kitchen cabinet and chemicals in the resident's bathroom cabinet. Deficiency issued. There are no guns, ammunition, swimming pool or bodies of water in the facility. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care. Food Service: Non-perishable and perishable food supply is not sufficient for number of residents in care. Deficiency issued. Dishes, cups, and utensils were also stored properly.

Nedra Brown	TELEPHONE: (951) 202-5776
Michelle Echeverria	TELEPHONE: 951-248-0345
	DATE: 10/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024

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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PARADISE FOR THE ELDERLY #2	FACILITY NUMBER: 361800177
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the administrator did not comply with the section cited above by leaving medication and chemicals accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/28/2024
	Plan of Correction
1 2 3 4	Staff made the medication and chemicals inaccessible. Administrator stated that she will conduct training with staff on regulation cited and submit proof of attendance sheet to LPA via email by 11/11/24.

Type A

Section Cited

HSC

1569.17(b)

Licensing

(b) In addition to the applicant, the provisions of this section shall apply to criminal record clearances and exemptions for the following persons: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the administrator did not comply with the section cited above by having the future licensee/administrator managing staff without transfer of criminal background clearance which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/29/2024
	Plan of Correction
1 2 3 4	Administrator stated that she will be present when training future licensee/administrator and submit a statement of understanding on regulation cited by POC due date.

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: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024

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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PARADISE FOR THE ELDERLY #2	FACILITY NUMBER: 361800177
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87555(b)(26)

General Food Service Requirements

(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the administrator did not comply with the section cited above by having a 7 day supply of nonperishables and 2 day supply of perishables which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/29/2024
	Plan of Correction
1 2 3 4	Administrator stated that she will purchase 7 day supply of nonperishables and 2 day supply of perishables and send pictures of food and receipts to LPA via email by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024

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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PARADISE FOR THE ELDERLY #2	FACILITY NUMBER: 361800177
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(c)

Maintenance and Operation

(c) All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the administrator did not comply with the section cited above by having a window screen on one of the resident's bedroom which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/01/2024
	Plan of Correction
1 2 3 4	Administrator stated that she will purchase and install a window screen on the resident's bedroom and send picture to LPA via email by POC due date.

Type B

Section Cited

CCR

87303(e)(4)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (4) Grab bars shall be maintained for each toilet, bathtub and shower used by residents. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the administrator did not comply with the section cited above by providing a grab bar for the toilet in one of the resident's bathroom which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/01/2024
	Plan of Correction
1 2 3 4	Administrator stated that she will install a grab bar for the toilet in the resident's bathroom and send picture to LPA via email by POC due date.

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: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024

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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PARADISE FOR THE ELDERLY #2	FACILITY NUMBER: 361800177
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(a)(3)(D)

Personal Accommodations and Services

(D) Hygiene items of general use such as soap and toilet paper. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the administrator did not comply with the section cited above by providing hygiene items to all residents which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/01/2024
	Plan of Correction
1 2 3 4	Administrator stated that she will purchase all types of hygiene items for residents and send a picture of items and receipts to LPA via email by POC due date.

Type B

Section Cited

CCR

87412(f)

Personnel Records

(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the adminstrator did not comply with the section cited above by having all personnel records available for audit and inspection which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/01/2024
	Plan of Correction
1 2 3 4	Administrator stated that she will submit a statement of understanding on regulation cited to LPA via email by POC due date.

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: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024

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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PARADISE FOR THE ELDERLY #2	FACILITY NUMBER: 361800177
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)(11)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the administrator did not comply with the section cited above by not having record of a health screening for a staff which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/01/2024
	Plan of Correction
1 2 3 4	Administrator stated that she will locate the staff's health screening record and send a copy to LPA via email by POC due date.

Type B

Section Cited

CCR

87506(b)

Resident Records

(b) Each resident's record shall contain at least the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the administrator did not comply with the section cited above by maintaining complete and updated resident records which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/01/2024
	Plan of Correction
1 2 3 4	Administrator stated that she will review, update and complete the resident records. Administrator will submit a statement of understanding on regulation cited to LPA via email by POC due date.

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: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024

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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PARADISE FOR THE ELDERLY #2	FACILITY NUMBER: 361800177
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the administrator did not comply with the section cited above by conducting disaster drills quarterly and maintaining a record which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/04/2024
	Plan of Correction
1 2 3 4	Administrator stated that she will train staff on regulation cited and send a copy of attendance sheet to LPA via email by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024

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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PARADISE FOR THE ELDERLY #2	FACILITY NUMBER: 361800177
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87633(a)(2)

Hospice Care for Terminally Ill Residents

(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility, when all of the following conditions are met: (2) The licensee remains in substantial compliance with the requirements of this section, with the provisions of the Residential Care Facilities for the Elderly Act (Health and Safety Code Section 1569 et seq.), all other requirements of Chapter 8 of Title 22 of the California Code of Regulations governing Residential Care Facilities for the Elderly, and with all terms and conditions of the waiver. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the administrator did not comply with the section cited above by not remaining in compliance with the terms and conditions of the hospice waiver which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/04/2024
	Plan of Correction
1 2 3 4	Administrator stated that she will submit a hospice waiver increase request to the regional office by POC due date and send a copy to LPA via email by POC due date.

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: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024

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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PARADISE FOR THE ELDERLY #2	FACILITY NUMBER: 361800177
	VISIT DATE: 10/28/2024

NARRATIVE

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Yards/Outside: One shaded patio, a side gate with self-latching handle on the left and right side of the house that leads into the backyard, one shed used for storage and a garage housing the washer and dryer. All outdoor pathways were free of obstructions. LPA observed a missing window screen in bedroom #6. Deficiency issued.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPA reviewed resident files for admission agreements, updated physician reports, and needs and services plans. LPA observed issues on the resident records like no physician's report updated per resident's diagnosis, incomplete and missing appraisals, missing physician's signature on physician report. Deficiency issued. LPA observed that the facility did not remain in compliance with the hospice waiver granted for 3 and not 4. Deficiency issued. LPA also reviewed staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA observed a missing health screening for one staff. Deficiency issued. LPA observed that the facility did not have the active administrator's and the pending licensee/administrator files available for inspection. Deficiency issued. LPA observed that the pending licensee/administrator who oversees management when the active licensee/administrator is not present did not have a transfer of criminal background clearance. Deficiency with civil penalty issued. LPA observed that the facility did not have a record of disaster drills conducted quarterly and was able to provide the only drill conducted on 9/20/24. Deficiency issued. LPA observed that the Emergency Disaster Plan was not reviewed/updated since 8/3/23. Technical violation issued.

Deficiencies, a technical violation and a civil penalty were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102TV, LIC421BG and appeal rights were discussed and copies were provided to staff (pending Licensee/Administrator) Faryal Khan.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024

LIC809 (FAS) - (06/04)

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