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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603340
Report Date: 01/25/2022
Date Signed: 01/25/2022 06:37:08 PM

Document Has Been Signed on 01/25/2022 06:37 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME:EXCLUSIVE RAYA'S PARADISE, INC.FACILITY NUMBER:
197603340
ADMINISTRATOR:ISRAEL & MOTI GAMBURDFACILITY TYPE:
740
ADDRESS:341 N. LA JOLLA AVE.TELEPHONE:
(323) 851-2517
CITY:LOS ANGELESSTATE: CAZIP CODE:
90048
CAPACITY: 6CENSUS: 6DATE:
01/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Robin Culver and Ruzanna SukiasyanTIME COMPLETED:
04:11 PM
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Licensing Program Analyst (LPA) Jey Cardenas conducted an unannounced required annual visit with a primary focus on Infection Control measures using the new CARE Inspection Tools. Upon arrival at the facility, LPA Cardenas met with house manager, Ruzanna Sukiasyan and conducted a risk assessment, based on the assessment, the facility is clear of Covid-19 infection. Executive Director, Robin Culver arrived shortly after and assisted LPA, the purpose of today’s visit was explained. The facility is licensed for six non-ambulatory residents age 60 and over; hospice waiver approved for one (1).

Ruzzanna and LPA toured the inside and outside grounds of the facility. The one story residential house consists of living room, kitchen, dining room, six(6) resident bedrooms, six(6) bathrooms, laundry, shaded patio area, and garage.

During the tour, LPA observed the facility’s infection control practices. LPA verified that the facility has an approved mitigation plan report. LPA was properly screened for Covid-19 symptoms, temperature was checked and documented. LPA observed a sanitizing station at the facility entrance; visitors log with Covid-19 screening and temperature log, PPE supplies are readily available to staff, and an additional 60 day supply of PPE was observed in the garage area. Sufficient paper, cleaning, and disinfecting supplies were observed. LPA observed all staff wear a face covering. CCLD PINS were readily available to staff and residents.

Bedrooms were inspected, all six (6) bedrooms are private with a private bathroom. Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident personal belongings was observed.

Three (3) resident bathrooms were checked, sufficient soap and towels were observed. Toilets and water faucets worked properly, grab bars were secure, the shower was free of mold/mildew, the water temperature measured at 117 degrees F in bathroom. Comfortable temperature was maintained in the facility.

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Jey Cardenas
LICENSING EVALUATOR SIGNATURE: DATE: 01/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/25/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME: EXCLUSIVE RAYA'S PARADISE, INC.
FACILITY NUMBER: 197603340
VISIT DATE: 01/25/2022
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LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Centrally stored medications were observed stored in their originally received containers and kept safe and locked and inaccessible to residents in care. Dual/ hardwired Carbon Monoxide/ Smoke Detector was tested, and found to be in operating condition. The facility has one (1) Fire Extinguisher, which was checked and found to be fully charged, & recently purchased. The First Aid kit was available and fully stocked. There are no security bars or weapons on the premises.

Outside grounds were toured, and no bodies of water were observed. Walkways around the home were clear of hazards. Common areas were clean and clear of hazards; doorways were free of obstructions. No bodies of water present.

No deficiencies were cited during this visit.

Advisory Notes with technical assistance were issued:

1. Ensure all staff is fit tested for respirators.

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Jey Cardenas
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2022
LIC809 (FAS) - (06/04)
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