361881297-3-10-2022-56-AS-AGOG-CCDPFZ-20220310101734

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361881297
Report Date: 03/10/2022
Date Signed: 03/10/2022 10:17:41 AM

Document Has Been Signed on 03/10/2022 10:17 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME:	ROYAL PARADISE SENIOR LIVING LLC, THE		FACILITY NUMBER:	361881297
ADMINISTRATOR:	CUSTODIO, ERNESTO JR		FACILITY TYPE:	740
ADDRESS:	10132 DEVON ST		TELEPHONE:	(858) 924-2244
CITY:	RANCHO CUCAMONGA	STATE: CA	ZIP CODE:	91730
CAPACITY:	6	CENSUS: 0	DATE:	03/10/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Ernesto Custodio Athena Custodio, applicants		TIME COMPLETED:	10:40 AM

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) Amy Goldenberg conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. An initial application to operate a Residential Care Facility for the elderly was submitted to the Central Applications Unit (CAU) on 01/06/22 for a total capacity of 6 non-ambulatory residents. Fire Clearance was granted 02/03/2022. LPA Goldenberg observed the following: Structure: Facility was a single story house with four (4) resident bedrooms, two bathrooms, living room areas, dining area, and kitchen area. Heating/Cooling System: Central heating and air conditioning systems. Bedrooms: All bedrooms were adequately furnished with bed, chair, large closets, appropriate linens, adequate lighting, and an operational smoke alarm. Bathrooms: Bathrooms have a working toilet, wash basin, and shower with an adequate supply of towels, toilet paper, and toiletries. Water temperature measured by LPA at 108.3 degrees F. Kitchen: An adequate supply of dishes, glasses, utensils, pots and pans were observed. Cleaning supplies and knives/sharp instruments were secured in a locked cabinet and drawer. There was adequate room for food storage. Refrigerator/freezer were in working condition and had sufficient storage for perishable food. There was adequate seating for meals.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022

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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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
, CA 92507

FACILITY NAME: ROYAL PARADISE SENIOR LIVING LLC, THE	FACILITY NUMBER: 361881297
	VISIT DATE: 03/10/2022

NARRATIVE

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Living/Family room: Furnished with safe and adequate seating and furnishings. All items appear to be in good repair.

Linens and Hygiene Supplies: An adequate supply of back up linens are available.

Yards/Outside: A large umbrella is provided for shade. Adequate outdoor seating is present. There were no obstructions to walkways. There were no bodies of water observed anywhere on the property.

Garage: Laundry area with washer and dryer were located just inside the house near the garage exit. Laundry detergents and cleaning solutions are to be secured behind the locked garage door. Garage was organized and free of obstructions.

Emergency Phone Numbers, and Exit Plan: Let-Us-No poster, and clients rights are available prominently for resident review.

General items: The facility has 6 Smoke alarms and 1 carbon monoxide detectors. These were tested and operational. LPA observed a facility phone and it was verified to be operational by LPA.

COMPONENT III was reviewed with the applicant during this Pre-Licensing Inspection.

This facility meets the requirements for licensure. Applicant was provided with a copy of this report during the exit interview.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022

LIC809 (FAS) - (06/04)

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