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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607979
Report Date: 07/28/2022
Date Signed: 07/28/2022 01:11:30 PM

Document Has Been Signed on 07/28/2022 01:11 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:EXCLUSIVE RAYA'S PARADISE, INC.FACILITY NUMBER:
197607979
ADMINISTRATOR:MICHAEL GAMBURDFACILITY TYPE:
740
ADDRESS:851 N. GARDNER STREETTELEPHONE:
(323) 851-2517
CITY:LOS ANGELESSTATE: CAZIP CODE:
90046
CAPACITY: 4CENSUS: 1DATE:
07/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:57 AM
MET WITH:Brian RosalesTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) LaQueena Lacy arrived at the facility at approximately 10:57am on 07/28/2022 to conduct a One (1) year Required Infection Control visit. LPA meet with Brian and explained the purpose of this visit. The facility has an approved mitigation plan on file.

A tour of the physical plant was conducted at 11:04am and the following was observed:

The facility has a fire clearance for four (04) non-ambulatory residents, with a Hospice Waiver for (04). The facility has one main entrance being used, there are required Covid-19 prevention signage (hand washing, coughing etiquette, and physical distancing) posted. The PPE screening station is located on a desk upon entry equipped with sufficient PPE readily accessible, thermometer, sign in sheet, hand sanitizer, gloves, mask, at the time of visit. The facility maintains a temperature at 74 degrees Fahrenheit. The facility has two (02) fire extinguishers located in the living room with a service tagged dated 05/07/2022 and at the rear of the facility near bedroom number (02) with a service tag dated 05/17/2022. The facility has (02) bedrooms and (2) bathrooms. The facility has a sister facility Exclusive Raya’s Paradise INC (197607055) 849 N Gardner Los Angeles, CA 90046 which is a duplex with access between the (02) facilities.

Kitchen: At 11:07am LPA observed the kitchen to be clean and free from obstruction. Appliances observed
to be in good repair and functional. Sharps are stored in a kitchen drawer near the stove observed to be locked and inaccessible to residents. LPA observed juice, milk, water, tea, fresh fruit in the refrigerator. The facility has a food waiver on file.

Continued on LIC809C.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: LaQueena Lacy
LICENSING EVALUATOR SIGNATURE: DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2022
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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: EXCLUSIVE RAYA'S PARADISE, INC.
FACILITY NUMBER: 197607979
VISIT DATE: 07/28/2022
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Laundry Room: At 11:14am LPA observed the laundry room located adjacent to the kitchen inaccessible to residents observed to be clean and free from obstruction and debris. LPA observed a plastic shed locked located outside the facility exit door in the laundry room to be locked and storing toxins, bleach, laundry soap and cleaning supplies.

Bedrooms: At 11:19am LPA observe (02) bedroods to be appropriately furnished with sufficient lighting. LPA observed appropriate bed linen and comforters on all beds. All bedrooms observed to be clean and clear from obstruction.
Bathroom: At 11:25am LPA observed (02) bathrooms, one is designated as a staff bathroom and is inaccessible to residents, the second bathroom is not being used, residents use the bathroom located on the shared property side of the sister facility. The water temperature measured 118.3 degrees Fahrenheit. LPA observed appropriate grab bars located in the shower and around the toilet. Non-skid mats were in the shower. Bathrooms are stocked and equipped with soap and paper towels. Hand towels are not shared.
Medications: LPA observed the medication cart at 11:31am located at the entrance of the facility observed to be locked and inaccessible to residents storing medication. The facility has (02) first aid kits located in the staff bathroom and near the PPE screening station at the entrance of the facility.
Living, dining room and common areas: At 11:37am LPA observed these areas to be appropriately furnished with tables and chairs and adequate lighting to be neat and clean and free from obstruction. At 11:44am LPA tested and observed the smoke detector located in the hallyway, the carbon monoxide detector located in the dining room to operational and functioning. At 11:48am LPA observed a cupboard located in the living room to be storing activities (board games, puzzles, bingo etc). LPA observed auditory alarms on exit doors, observed to operational and functioning. PPE is located in the dining room in a plastic bin labeled PPE.
Backyard: At 11:53am LPA observed the outside area and surrounding grounds of the facility to be clean and clear from debris and obstruction. The back yard provides access to the sister facilities which is a shared back yard space located on the property, equipped with table and owning for seating, chairs, and extra table for lounging underneath a shaded area. The front of the facility also has a shaded area with a bench and table for lounging. LPA observed a detached garage at 11:58am to be locked and storing extra personal care items, incontinent supplies, cleaning products, PPE, constructions supplies, and tools. No bodies of water observed or located on the premises.
No deficiencies cited, exit interview conducted, and a copy of report issued
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: LaQueena Lacy
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022
LIC809 (FAS) - (06/04)
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