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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197604444
Report Date: 10/31/2024
Date Signed: 10/31/2024 04:42:07 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/27/2023 and conducted by Evaluator Mariana Agban
COMPLAINT CONTROL NUMBER: 31-AS-20230927105732
FACILITY NAME:RAYA'S PARADISE, INC.FACILITY NUMBER:
197604444
ADMINISTRATOR:MICHAEL GAMBURDFACILITY TYPE:
740
ADDRESS:1533 N. STANLEY AVE.TELEPHONE:
(323) 969-0316
CITY:LOS ANGELESSTATE: CAZIP CODE:
90046
CAPACITY:6CENSUS: 6DATE:
10/31/2024
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Brian Rosales- Administrator TIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff did not reposition a resident, resulting in an unstageable pressure injury.
Staff did not seek timely medical attention for a resident.
Staff did not adequately bathe a resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mariana Agban conducted an unannounced subsquent complaint visit to investigate the above stated allegations. LPA met with the Administrator and explained the reason for the visit. LPA conducted a physical plant tour, to ensure the health and safety of the residents are protected and the physical plant is in compliance with Title 22 Regulations. LPA obtained copies of the resident roster and staff roster.

Allegation: Staff did not reposition a resident, resulting in an unstageable pressure injury.
It is alleged that the R1 developed a pressure injury while living at the facility. It is also alleged that the pressure injury worsened due to the failure of repositioning. LPA obtained hospital records which indicate that on 09/11/23 R1 presented with stage 3 or 4 pressure injury on the coccyx. Interview with Staff 1 (S1) revealed that it was reported to S1 sometime on or around September 8th, 2023 that there was slough coming out of R1's patch foam on the coccyx. R1 received Home Heath services and staff was instructed to reposition R1 every 2 hours. (Conintue on 9099C)
Substantiated
Estimated Days of Completion:
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 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.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 31-AS-20230927105732
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 A
11/01/2024
Section Cited
CCR
87615(a)(1)
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Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries.
This requirement was not met as evidenced by:
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Licensee and Administrator will schedule 4 hours vendorized training for themselves and all staff. Verification of the scheduled training with the credentials of the trainer will need to be emailed to the LPA by 11/01/24
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Based on information obtained during the investigation the licensee did not comply with the cited section by retaining R1 at the facility with a stage 3 or 4 pressure injury which posed an immediate health and safety and personal rights risk to R1.
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Verification of completed training will need to be submitted to the LPA by 11/22/24
Type A
11/01/2024
Section Cited
CCR
87616(a)
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As specified in Section 87209, Program Flexibility, the licensee may submit a written exception request if he/she agrees that the resident has a prohibited and/or restrictive health condition but believes that the intent of the law can be met through alternative means. This requirement was not met as evidenced by:
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Administrator will schedule and attend 1 hours vendorized training related to the cited section. Verification of the scheduled training with the credentials of the trainer will need to be emailed to the LPA by 11/01/24
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Based on information obtained during the investigation, the licensee did not comply with the cited section by not submitting an exception request to retain R1 at the facility with a prohibited health condition, which posed an immediate health and safety and personal rights risk to R1.
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Verification of completed training will need to be submitted to the LPA by 11/22/24.
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
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 31-AS-20230927105732
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 A
11/01/2024
Section Cited
CCR
87464(f)(1)
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Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by: Based on the information obtained during the course of the investigation
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Licensee, Administrators will schedule 2 hours vendorized training for themselves and all staff related to the cited section.
1) Verification of the scheduled training with the credentials of the trainer will need to be emailed to the LPA by 11/01/24
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The licensee failed to comply with the cited section by not following instructions provided by medical professional related to the care of R1 which resulted in R1 developing prohibited health conditions and posing an immediate health and safety and person rights risk to R1.
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Verification of completed training will need to be submitted to the LPA by 11/22/24. Because this violation resulted in resident developing prohibited health conditions as a result of improper care an immediate civil penalty in the amount of $500 is issued.
Type B
11/22/2024
Section Cited
CCR
87464(f)(4)
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(f)Basic services shall at a minimum include: (4)Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports.
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Administrator will conduct training for all staff to address this section of the regulation. An attendance sheet will be submitted to the LPA by the POC date
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This requirement was not met as evidenced by: R1 didn't receive adequate bathing. This poses a potential health, safety or personal rights risk to residents 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
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 31-AS-20230927105732
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 A
11/01/2024
Section Cited
CCR
87465(g)
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Incidental Medical and Dental Care. The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health
This requirement was not met as evidenced by:
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Administrator will schedule and attend 1 hours vendorized training related to the cited section. Verification of the scheduled training with the credentials of the trainer will need to be emailed to the LPA by 11/01/24
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Based on information obtained, R1 was taken to the hospital by a family member and diagnosed with pressure injuries. Facility staff failed to seek medical attention for R1. This posses an an immediate health and safety and personal rights risk to persons in care.
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Verification of completed training will need to be submitted to the LPA by 11/22/24.
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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
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20230927105732
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 10/31/2024
NARRATIVE
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LPA obtained records of Home Health and of the Staff Daily Log. Documents revealed that Staff didn't reposition R1 every 2 hours as instructed resulting in an unstageable pressure injury. Based on information obtained the allegation is deemed Substantiated at this time.

Allegation: Staff did not seek timely medical attention for a resident.
It was alleged that staff did not seek timely medical attention for R1. On 09/10/23 R1 was taken to the hospital by a family member and was diagnosed with UTI, sepsis, and pressure injuries. S1 denied the allegation. Interview with S1 revealed that facility staff didn’t know the stage of the wound. S1 stated that there was a miscommunication between home health and facility staff. Interview with S2 revealed that they were unaware of R1's medical condition and that resident's medical conditions are being supervised by S1. Based on information obtained the allegation is deemed Substantiated at this time.

Allegation: Staff did not adequately bathe a resident
It was alleged that staff did not adequately bathe R1. Interviews with 4 out of 4 staff denied the allegation. Records review indicated that R1 had received a one time shower since their admission at the facility. S2 stated that facility staff failed to document daily showers and thus S2 conducted an in-service training to address the issue. Based on information obtained the allegation is deemed Substantiated at this time.


Per California Code of Regulations (CCR), Title 22, see LIC 9099-D for deficiencies cited. An immediate civil penalty of $500 is also assessed. The licensee was informed that a civil penalty might be assessed based on the Health and Safety Code 1569,49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f). Exit interview conducted, appeal rights given and copy of this report signed and delivered.
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 licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5