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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604444
Report Date: 10/31/2024
Date Signed: 10/31/2024 04:44:34 PM

Document Has Been Signed on 10/31/2024 04:44 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:RAYA'S PARADISE, INC.FACILITY NUMBER:
197604444
ADMINISTRATOR/
DIRECTOR:		MICHAEL GAMBURDFACILITY TYPE:
740
ADDRESS:1533 N. STANLEY AVE.TELEPHONE:
(323) 969-0316
CITY:LOS ANGELESSTATE: CAZIP CODE:
90046
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
10/31/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:00 PM
MET WITH:Brian RosalesTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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In conjunction to the complaint 31-AS-20230927105732 LPA Mariana Agban conducted a case management- Deficiencies visit. During the complaint investigation, it was confirmed that Licensee failed to submit Special Incident Report (SIR) for Resident 1(R1) to CCL regarding the development of the pressure injury. LPA conducted a file review and didn't observe SIR on file.


Deficiencies Cited. Exit Interview Conducted. Report Issued
Eva MillerTELEPHONE: (818) 596-4373
Mariana AgbanTELEPHONE: 818-738-4525
DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2024
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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Document Has Been Signed on 10/31/2024 04:44 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: RAYA'S PARADISE, INC.
FACILITY NUMBER: 197604444

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/22/2024
Section Cited
CCR
80061(b)

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Reporting Requirements. Upon the occurrence…a report shall be made to the licensing agency..., a written report ...within seven days following the occurrence of such event.
This requirement was not met as evidence by:
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 Administrator will conduct in service training reviewing the regulation section about reporting requirements. The Administrator will provide all training materials and signatures of all staff that have attended the training by the POC due date.
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Based on file document review, the Licensee did not comply with the section cited above. Licensee didn't submit SIR for R1 regarding the development of the pressure injury. This poses a potential health and safety risk to clients in care.
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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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2024
LIC809 (FAS) - (06/04)
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