<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197604445
Report Date: 01/06/2022
Date Signed: 01/06/2022 02:57:32 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/12/2020 and conducted by Evaluator LaQueena Lacy
COMPLAINT CONTROL NUMBER: 31-AS-20200312103932
FACILITY NAME:RAYA'S PARADISE, INC.FACILITY NUMBER:
197604445
ADMINISTRATOR:MOTI GAMBURDFACILITY TYPE:
740
ADDRESS:1156 N. GARDNER ST.TELEPHONE:
(323) 851-2517
CITY:WEST HOLLYWOODSTATE: CAZIP CODE:
90046
CAPACITY:11CENSUS: 6DATE:
01/06/2022
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Robin Culver & Ruzanna SukiassyanTIME COMPLETED:
02:55 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident had unwitnessed fall resulting in a fracture
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) LaQueena Lacy conducted unannounced subsequent complaint visit to the facility. LPA met the Director Robin Culver and Administrator Ruzanna Sukiassyan and explained that this visit was conducted to deliver final investigation report of the above noted allegations. It was reported that resident #1 (R1) fell and sustained fractures and a hematoma. This allegation was investigated by Tiffany Brunelli, a Senior Investigator from The Community Care Licensing Investigation Bureau. During the investigation, between 05/20/2020 and 07/07/2020, IB investigator spoke with the Administrator, facility manager, Medical professionals working for the facility and other staff assisting R1 at the facility. In addition, IB investigator spoke with other witnesses involved in R1’s care and supervision. Interviews revealed that R1 was admitted to the facility on 02/10/2020. Prior to admission R1 was residing in another RCFE, where R1 suffered two (02) falls, resulting injuries on their limbs and head. R1’s pre-admission appraisal was completed based on the information received from R1’s responsible person, who informed the facility personnel about R1’s falls resulting in injuries. Staff also was informed that although R1 need transfer assistance, R1 often tries to get out of bed. Continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 586-4368
LICENSING EVALUATOR NAME: LaQueena LacyTELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2022
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 6
Control Number 31-AS-20200312103932
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: RAYA'S PARADISE, INC.
FACILITY NUMBER: 197604445
VISIT DATE: 01/06/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The functional capability assessment was conducted via tele-visit, by the administrator in training, who was a licensed medical professional. On 02/10/2020, Upon admission to the facility R1 was identified by the facility staff as a fall risk resident requiring close supervision. Although facility staff had knowledge that R1 must be under the staff supervision all the time, between 02/17/2020 and 03/05/2020 R1 had two (02) fall incidents with injuries and both times staff stepped away and was not present at the time of fall. Between 03/17/2020 and 05/23/2020 IB investigator reviewed various facility records as well as medical records obtained from the hospital. The information revealed from the documents verified and the information revealed from the interviews.
Therefore, based on the interviews and record review, the allegation is SUBSTANTIATED at this time.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 586-4368
LICENSING EVALUATOR NAME: LaQueena LacyTELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 31-AS-20200312103932
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: RAYA'S PARADISE, INC.
FACILITY NUMBER: 197604445
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/02/2022
Section Cited
CCR
87464(d)
1
2
3
4
5
6
7
87464 (d) Basic Services (d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs…and providing other basic services either directly or through outside resources. This requirement is not met as evidenced by;
1
2
3
4
5
6
7
Licensee provided in-service training to all staff, regarding fall risk, transferring and repositioning of residents etc. This citation was cleared during this visit.
8
9
10
11
12
13
14
Based on interviews and record review, the facility staff did not provide required supervision to the resident, who was at risk of fall. Within a short period of time, while R1 was left unsupervised, R1 had 2 fall incidents. This poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Naira MargaryanTELEPHONE: (818) 586-4368
LICENSING EVALUATOR NAME: LaQueena LacyTELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/12/2020 and conducted by Evaluator LaQueena Lacy
COMPLAINT CONTROL NUMBER: 31-AS-20200312103932

FACILITY NAME:RAYA'S PARADISE, INC.FACILITY NUMBER:
197604445
ADMINISTRATOR:MOTI GAMBURDFACILITY TYPE:
740
ADDRESS:1156 N. GARDNER ST.TELEPHONE:
(323) 851-2517
CITY:WEST HOLLYWOODSTATE: CAZIP CODE:
90046
CAPACITY:11CENSUS: DATE:
01/06/2022
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Robin Culver & Ruzanna SukiassyanTIME COMPLETED:
02:55 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not following Dr. orders for a pureed diet
Staff did not provided a copy of the care plan to the responsible person
Staff did not provide a level of care rate sheet upon admission
Staff denied resident food
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
It was reported that R1’s responsible party never received a copy of the care plan nor did she sign a care plan and staff never provided a level of care rate upon admission. The addendum to the level of care rate was provided later, after R1 fell. Prior to initial Licensing Visit LPA Margaryan made pre-investigation contact and spoke with witnesses. On 03/12/20 at 2:30pm LPA Margaryan spoke with the facility Social Worker, and facility manager. On 03/20/2020 at 1:40pm LPA Margaryan spoke with the Licensed Vocational Nurse (LVN) working for the facility. Interviews revealed that after R1’s admission to the facility, the LVN working for the facility reviewed R1’s pre-admission appraisal and observed and assessed R1. Upon assessment, R1’s care plan was completed based on pre-admission appraisal which was conducted via face-time. Subsequently, R1’s responsible party was invited for a meeting to discuss R1’s care plan. The responsible party postponed the meeting and requested to send a care plan and other documents for review and signature via e-mail. Documents were sent to R1’s responsible party for review and signature via docushare. The signed copies were never sent back to the facility. R1’s care plan was discussed on 03/10/2020 and upon discussion, the
Continued on LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 586-4368
LICENSING EVALUATOR NAME: LaQueena LacyTELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 31-AS-20200312103932
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: RAYA'S PARADISE, INC.
FACILITY NUMBER: 197604445
VISIT DATE: 01/06/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
responsible party made a decision to move R1 from the facility. On 02/12/2020 at 2:30pm, LPA Margaryan requested various facility records for review. On 03/12/2020 at 3:30pm LPA Margaryan spoke with R1’s responsible party that was present at the facility during licensing visit and she indicated that she did receive an e-mail from the facility. However, the attached documents were incomplete. R1’s responsible party was unable to provide copies of the incomplete documents received from the facility staff via-e-mail. A review of the facility records completed on 03/25/2020 at 4:00pm verified that R1’s care plan and other relevant documents were completed upon admission and were e-mailed to R1’s responsible party for review and signature.

Based on the interviews and record review, there is no sufficient information to support the allegations. Therefore, the allegations are UNSUBSTANTIATED at this time.



Staff denied resident food.
It was reported that R1 was hungry and staff refused to give R1 food. On 03/12/2020 LPA Margaryan was present at the facility between 8:30am and 5:30pm. During licensing visit LPA Margaryan inspected the kitchen and observed the facility food supply. On 03/12/2020 around 12:00pm LPA observed R1 eating lunch and facility staff providing feeding assistance. The staff prepared a soft food and soup for R1. On 03/12/2020 at 2:00pm LPA Margaryan spoke with the facility staff preparing the food for the residents. Interviews revealed that every morning in addition to other food items served to R1, staff also serves R1 two (02) boiled eggs. On 03/12/2020 around 10am, while LPA was present at the facility, R1’s family member came to visit R1, a few minutes later, R1’s family member came to the kitchen and accused staff of not feeding R1. The staff explained that R1 already had breakfast and as usual had two (02) boiled eggs. The family member continued to insist to give two (02) more eggs to R1 and the staff offered to give R1 other foods but no more eggs. On 03/12/2020 around 2:30pm, LPA Margaryan spoke with R1 and R1 was unable to remember what they had for breakfast and lunch.
Based on inspection, observation and interviews, there is no sufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 586-4368
LICENSING EVALUATOR NAME: LaQueena LacyTELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 31-AS-20200312103932
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: RAYA'S PARADISE, INC.
FACILITY NUMBER: 197604445
VISIT DATE: 01/06/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Staff are not following Dr. orders for a pureed diet:
It was reported that R1 is suppose to receive a pureed diet and the staff feds the resident soup. During investigation on 03/12/2020 LPA Margaryan inspected the kitchen and observed the facility food supply. The facility had appropriate quantity and variety of food. On 03/12/2020 around 12:00pm LPA observed R1 eating lunch and observed facility staff assisting R1. R1 was served a soft food and soup. On 03/12/2020 between 2:00pm and 2:45pm, LPA Margaryan spoke with the administrative personnel and the facility staff preparing the food for the residents. Interviews revealed that as per physician report submitted to the facility, R1 was not on a prescribed medical diet. However, as per R1’s responsible parties request, the staff was making soft food for R1. On 03/25/2020 at 4:00pm LPA Margaryan reviewed R1’s physician report signed on 09/10/2019 and the document does not indicate that R1 was on a special diet.
Based on the interviews, observation and record review, there is no sufficient information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 586-4368
LICENSING EVALUATOR NAME: LaQueena LacyTELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6