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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881297
Report Date: 03/19/2025
Date Signed: 03/19/2025 01:24:34 PM

Document Has Been Signed on 03/19/2025 01:24 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ROYAL PARADISE SENIOR LIVING LLC, THEFACILITY NUMBER:
361881297
ADMINISTRATOR/
DIRECTOR:		CUSTODIO, ERNESTO JRFACILITY TYPE:
740
ADDRESS:10132 DEVON STTELEPHONE:
(909) 919-6342
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91730
CAPACITY: 6CENSUS: 5DATE:
03/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Administrator Ernesto Custodio and Athina Custodio TIME VISIT/
INSPECTION COMPLETED:
01:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Raquel Hernandez made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Hernandez met with Administrators Ernesto Custodio and Athina Custodio. The capacity is (6) current census is (5). The facility sis a four (4) bedroom, two (2) bathroom home with a kitchen/dining area, living room and attached garage. The facility is Residential Care Facility for the Elderly (RCFE). LPA Hernandez was accompanied by Administrators Ernesto Custodio and Athina Custodio to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 70 degrees. LPA Hernandez inspected resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA tested water temperature to be at 111 degrees Fahrenheit. LPA Hernandez observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, labor laws, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files.

Food Service: More than seven (7) days’ supply of Non-perishable foods and more than two (2) days’ supply of perishable food supply were observed and sufficient for the number of residents in care.

Care & Supervision: The facility has sufficient number of staff to provide care and supervision to the residents in care.

**Continuation on LIC809-C**

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2025
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ROYAL PARADISE SENIOR LIVING LLC, THE
FACILITY NUMBER: 361881297
VISIT DATE: 03/19/2025
NARRATIVE
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Record Review: LPA Hernandez reviewed three (3) resident files for admission agreements, updated physician reports, pre-placement appraisals and needs and services plans. LPA Hernandez observed resident files reviewed were complete. LPA observed three (3) residents medications. LPA observed prescription label altered by no label being present for medication for Client #3 (C3). Deficiency will be issued. LPA observed for all (3) residents medications were not stored in a original container but moved to a different container. Deficiency will be issued. Additionally, LPA observed medication for all (3) residents to not be documented and signed in Medication Administration Record (MAR). Deficiency will be issued. Also, LPA advised Administrators when PRN medication is being taken it shall be documented with staff signature, resident's response and date and time taken. Technical Violation was given. LPA Hernandez reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with Tuberculosis (TB) test result. No issues were observed

Based on the observations made during today’s visit, deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809) (LIC809D) and (LIC9102) was discussed and provided to Administrator Ernesto Custodio and Athina Custodio along with copy of Appeal Rights.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/19/2025 01:24 PM - It Cannot Be Edited


Created By: Raquel Hernandez On 03/19/2025 at 01:01 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ROYAL PARADISE SENIOR LIVING LLC, THE
FACILITY NUMBER: 361881297

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(4)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having Client #3 (C3) medication label altered and with no label being present, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/20/2025
Plan of Correction
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Licensee stated they will get doctor prescribed medication order for C3 as well as centrally stored medication log for resident by Plan of Correction (POC) due date to LPA Hernandez.
Type A
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not ensuring all three residents medications are kept inside their original container, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/20/2025
Plan of Correction
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Licensee stated to submit staff training on administering medications by POC due date to LPA Hernandez
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 03/19/2025 01:24 PM - It Cannot Be Edited


Created By: Raquel Hernandez On 03/19/2025 at 01:01 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ROYAL PARADISE SENIOR LIVING LLC, THE
FACILITY NUMBER: 361881297

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above by not ensuring all three residents medications were documented on Medication Administration Record (MAR), which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/20/2025
Plan of Correction
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Licensee stated to submit staff training on documenting residents medications as well as for refusal of medication by Plan of Correction (POC) due date to LPA Hernandez.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2025


LIC809 (FAS) - (06/04)
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