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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004678
Report Date: 08/12/2025
Date Signed: 08/12/2025 12:19:10 PM

Document Has Been Signed on 08/12/2025 12:19 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:
08/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:04 AM
MET WITH:Alex Mathews Administrator (AD)TIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On this day Licensing Program Analyst (LPA) William Vanegas conducted an unannounced visit in order to complete an annual inspection. Upon arrival LPA Vanegas was greeted and granted entry by Care Giver (CG) Gerardo Contreras. LPA Vanegas explained the purpose of the visit, set up equipment and Administrator (AD) Alex Mathews joined the visit a few moments after LPA's arrival. LPA Vanegas began a tour of the facility and observed the following.

This is a two storied home with eight bedrooms five of which are used for staff on duty, and three of which are used for residents in care; these are shared rooms for residents. The facility also has three shared bathrooms as well. LPA Vanegas observed kitchen area to be clean and free of any mildew and debris. LPA Vanegas observed a two-day supply of perishable food, and a seven day supply of non-perishable food on hand, as well as a sufficient amount of emergency water. LPA Vanegas observed a refrigerator, gas stove, dishwasher, microwave, washer, and dryer all appeared to be in good repair, and tested operational.

LPA Vanegas observed all resident rooms to have required furnishings such as a bed, clean linens in good repair; meaning no strains or tares, chest drawers, and enough storage space to store personal belongings. LPA Vanegas observed all rooms to be large enough to walk about freely in their rooms, and no obstructions were observed blocking entry ways.
LPA Vanegas observed all resident restrooms to be clean and free of any mildew or debris, LPA Vanegas observed water faucets, and toilets to be operational, restrooms had all required furnishings such as grab bars, slip resistant floor matts, and shower chair. Water temperature tested between 111.2 and 111.5 degrees.
CONTINUED ON LIC809C
NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: William Vanegas
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 08/12/2025
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LPA Vanegas observed all fire extinguishers to be fully charged, and up to date. LPA Vanegas observed all smoke and carbon monoxide detectors to be in good repair, and tested operational. LPA Vanegas observed first aid kit to have all required items such as bandages, tweezers, scissors, adhesive tape, a thermometer, and a first aid manual.

LPA Vanegas observed the outside of the facility, and observed a large backyard with an outdoor shaded sitting area, no obstructions were observed to be along the exit routes, side doors are self latching and unlocked. Front yard is clean, and no obstructions or debris were noted a long the walkways or the entry ways of the facility.

LPA Vanegas reviewed three staff files, and six resident files, all files (Staff and Resident) had all required files documented correctly, and annual staff training is up to date and documented. LPA Vanegas reviewed medications with AD and observed all medications to be documented correctly, and being administered per physicians orders.

Based on observations made during today's inspection no deficiencies will be cited per title 22 chapter 8 division 6 of the California Code of Regulations. An exit interview was conducted and with AD Alex Mathews and a copy of this report was provided to the facility.
NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: William Vanegas
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2025
LIC809 (FAS) - (06/04)
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