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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881234
Report Date: 12/12/2022
Date Signed: 12/12/2022 10:58:26 AM


Document Has Been Signed on 12/12/2022 10:58 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:PARADISE FOR THE ELDERLY #5FACILITY NUMBER:
361881234
ADMINISTRATOR:CHAND, SUNITAFACILITY TYPE:
740
ADDRESS:9225 BANYAN STREETTELEPHONE:
(909) 463-8432
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91737
CAPACITY:6CENSUS: DATE:
12/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Roza Kebede, Staff MemberTIME COMPLETED:
11:15 AM
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Licensing Program Analyst, Amber Coleman (LPA) arrived at the Paradise for the Elderly Facility to make an unannounced visit to conduct the Annual Inspection with a focus on Infection Control. When staff answered the door, LPA introduced self and stated the purpose of the visit. LPA was greeted and invited inside facility by staff member #1, Roza Kebede, (S1). S1 requested that LPA sign in and have temperature taken. LPA observed table with sign in sheet included extra masks, hand sanitizer and signage made available to residents and visitors. S1 contacted Licensee Renu Madahar, who arrived later during LPA's visit.

S1 and LPA walked through the facility for the inspection. Inspection Tool was utilized, Mitigation plan was referenced. During the inspection, LPA Coleman interviewed S1 pertaining to the facility's infection control measures and other health and safety measure. LPA Coleman observed necessary signs posted in the facility, including signs related to COVID-19, which were in accordance with the Department's guidelines. Licensee stated that the facility is equipped with sufficient PPE, hand hygiene supplies, and sufficient cleaning/disinfecting provisions. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the facility's infection control measures. The facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolation of residents, and properly caring for residents with COVID-19 positive results and/or exposures. The facility also has a plan in place to monitor residents regularly for any changes in condition and to subsequently notify the resident's physician and emergency personnel in the event the resident presents any COVID-19 symptoms. Fire and Carbon Monoxide Alarms were tested and found to be in proper working condition. Fire extinguishers last inspected January 2022. LPA thanked Licensee and S1 for their time and concluded the visit.

Based on the observations made during today’s visit, there were no deficiencies cited per Title 22, Division 6, of the California Code or Regulations. An exit interview to review this report was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2022
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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