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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530290
Report Date: 01/06/2025
Date Signed: 01/06/2025 11:39:58 AM

Document Has Been Signed on 01/06/2025 11:39 AM - 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:PARADISE SPRINGS FOR THE ELDERLY 2FACILITY NUMBER:
365530290
ADMINISTRATOR/
DIRECTOR:
MADAHAR, RENUFACILITY TYPE:
740
ADDRESS:8568 BAKER AVENUETELEPHONE:
(909) 463-8432
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91730
CAPACITY: 6CENSUS: 6DATE:
01/06/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Faryal Khan- LicenseeTIME VISIT/
INSPECTION COMPLETED:
11:50 AM
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Licensing Program Analysts (LPA) Javier Prieto conducted an announced pre-licensing visit to facility. LPA met with Facility Licensee Faryal Khan. The pending application is for a Residential Care Facility for Elderly (RCFE). There are currently six (6) residents in care. The Licensee accompanied LPA on a tour of the inside and outside of the facility. The home is a six (6) bedroom, three (3) bathroom home with a living room, dining room, activity room, kitchen, and detached garage. The physical plant, in general, was in good repair. The buildings and grounds are free from hazards. The indoor and outdoor passageways are free of obstruction. There are no pools, bodies of water, firearms, or ammunition. All bedrooms are furnished with a bed, nightstand, dresser, and chair. All bedrooms have adequate lighting for resident use. Bathroom's toilet, shower and tubs are in good repair and have non-skid mats. LPA measured and observed the water temperatures in the bathrooms to be at 113 degrees F. LPA observed food storage and preparation areas to be clean and sanitary. Refrigerator and freezer are maintained at appropriate temperatures. All appliances are clean and operating properly. Dishes, glasses, and utensils were in good condition. There is a sufficient supply of linens, towels, and personal hygiene items. The first aid kit was reviewed; all items are present. The backyard is completely enclosed with functioning gate to exit to front yard. The outdoor space is suitable for Resident use. LPA observed fully charged fire extinguisher present in the facility. Smoke alarms and carbon monoxide are present and functional. Medications were stored inside locked kitchen cabinet. Resident/Staff records were stored in staff office. Emergency disaster plans, personal rights, and complaint procedures were posted in a prominent area. There is adequate seating in the common areas. Facility had a supply of activities for the clients.

Pre-licensing inspection is complete, and no corrections are needed to be made. The Comp III presentation was completed during today's visit.

An exit interview was conducted, and a copy of this report was provided to Facility Licensee Faryal Khan.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE: DATE: 01/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/06/2025
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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