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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004678
Report Date: 08/28/2024
Date Signed: 08/28/2024 02:13:47 PM

Document Has Been Signed on 08/28/2024 02:13 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:PARADISE RESIDENTIAL SENIOR CARE 4FACILITY NUMBER:
306004678
ADMINISTRATOR/
DIRECTOR:		ROSA ANGELICA REYESFACILITY TYPE:
740
ADDRESS:24102 ADONIS STREETTELEPHONE:
(949) 305-9966
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 6DATE:
08/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:27 AM
MET WITH:Johan Mathews, Diana Manzano- AdministratorsTIME VISIT/
INSPECTION COMPLETED:
02:35 PM
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Licensing Program Analyst (LPA) Jessica Cho arrived at the facility unannounced for the purpose of conducting the Required 1-Year annual evaluation using the CARE Inspection Tool. LPA met with Administrators Johan Mathews and Diana Manzano and explained the reason for the visit. Course work for both administrators were verified during the visit and is pending certification with the Department.

The facility is a two story structure located in a residential neighborhood. Facility is licensed to operate for six (6) non-ambulatory and maintains a hospice waiver for six (6). There are six residents in care during today's visit of which two are in hospice. Two caregivers are on duty during the visit.

LPA observed the facility to be clean and sanitary. There are three resident bedrooms and two resident bathrooms on the first floor. The second floor consists of three staff bedrooms and a living room which is only utilized by two staff. There are two staff bathrooms on the second floor. All common areas were inspected including the attached two car garage. The residents' bedrooms were appropriately furnished. Beds and bedding supplies were in good condition, adequate lighting was provided, sufficient storage space for personal belongings were observed. Bathrooms were found to be in compliance, clean, and operational. The water temperature measured at 108.6 and 109.2 degrees Fahrenheit. Toxins, disinfectants, sharps, and medications were secured and inaccessible. LPA observed sufficient two-day supply of perishables and seven-day supply of non-perishable food. LPA toured the exterior portion of the facility. LPA observed the outdoor passageway free of obstruction. The exit gate was self-closing and self-latching. LPA observed sufficient seating and shading. Facility maintains two fire extinguishers one on each floor. Both were charged, and serviced on July 1, 2024. The auditory devices and dual-functioning smoke/carbon monoxide detectors were tested and operational on both floors. LPA observed the emergency disaster supplies including food/water in the garage. Emergency evacuation drills are being conducted. The first aid kit contains all necessary elements. LPA observed the required 'See Something, Say Something' (PUB475) poster in the correct size.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2024
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: PARADISE RESIDENTIAL SENIOR CARE 4
FACILITY NUMBER: 306004678
VISIT DATE: 08/28/2024
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LPA conducted an audit of six residents' files and two personnel files. No discrepancies were noted. Staff and resident interviews were conducted. Medications were audited for six residents. No discrepancies noted.

Based on the observations made during today's visit, no deficiency is being cited today.

An exit interview was conducted with Administrators Johan Mathews and Diana Manzano, and a copy of this report was provided at the end of the visit.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
LIC809 (FAS) - (06/04)
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