361881234-12-9-2021-18-AS-ABUO-C9JUZW-20211209150214

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361881234
Report Date: 12/09/2021
Date Signed: 12/09/2021 03:02:23 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:	PARADISE FOR THE ELDERLY #5		FACILITY NUMBER:	361881234
ADMINISTRATOR:	CHAND, SUNITA		FACILITY TYPE:	740
ADDRESS:	9225 BANYAN STREET		TELEPHONE:	(909) 463-8432
CITY:	RANCHO CUCAMONGA	STATE: CA	ZIP CODE:	91737
CAPACITY:	6	CENSUS: 0	DATE:	12/09/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	01:23 PM
MET WITH:	Renu Madahar		TIME COMPLETED:	03:06 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) Anna Bueno, conducted an announced pre-licensing inspection to the facility. The LPA met with administrators Pardeep and Renu Madahar. There are currently no residents in care. Application: The application is for a Residential Care Facility for the Elderly. The fire clearance has been granted for one (1) bedridden and five (5) nonambulatory residents. Buildings and Grounds: The home is composed of four (4) resident bedrooms, two (2) full bathrooms, a half bathroom for staff use only, a laundry room, a living room/intake and assessment area, a kitchen area, a dining area, a sitting/activity area, and a front and back yard areas. The interior/exterior walkways of the home were observed to be clutter free with no obstructions present. Smoke and Carbon Monoxide detectors were tested and operable. There are no pools or other bodies of water located at this facility home. According to Madahar, there are no weapons stored in the home. Rooms, furniture, beds, mattresses are all in good repair. Privacy is available in all bedrooms and bathrooms. The dining and living room areas are clutter free and in good condition. Bathrooms were observed to have non-slip flooring available. The water heater is within regulatory limits. Outdoor areas had sufficient room for activities and leisure. A washing machine and dryer are available and in working order. Storage and Supplies: Activities were observed to be available and in sufficient amount for the requested census. Medications will be stored inaccessible to any unauthorized individuals. Secured areas are available for facility files and resident files. The first aid kit was observed to be available and sharps are securely stored in a kitchen cabinet. Cleaning supplies are stored, inaccessible, under the kitchen sink and in the laundry room.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Anna Bueno	TELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021

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: PARADISE FOR THE ELDERLY #5	FACILITY NUMBER: 361881234
	VISIT DATE: 12/09/2021

NARRATIVE

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Linens, and equipment are all in good repair and sufficient for approved census. Fire extinguishers were observed to be fully charged.

Food Service: Utensils and dishware are sufficient for the requested capacity. The refrigerator and stove are in working order. Sharps are stored in a locked kitchen drawer, available only to authorized individuals.

An exit interview was conducted where this report was discussed with and a copy provided to Renu Madahar.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Anna Bueno	TELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021

LIC809 (FAS) - (06/04)

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