197607055-2-28-2022-31-AS-NMAN-CEBPNW-20220511112834

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607055
Report Date: 02/28/2022
Date Signed: 02/28/2022 01:54:50 PM

Unsubstantiated

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
02/18/2022 and conducted by Evaluator LaQueena Lacy

COMPLAINT CONTROL NUMBER: 31-AS-20220218161853

FACILITY NAME:	EXCLUSIVE RAYA'S PARADISE, INC.		FACILITY NUMBER:	197607055
ADMINISTRATOR:	MOTI MICHAEL GAMBURD		FACILITY TYPE:	740
ADDRESS:	849 N. GARDNER STREET		TELEPHONE:	(323) 528-3436
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90046
CAPACITY:	5	CENSUS: 4	DATE:	02/28/2022
		UNANNOUNCED	TIME BEGAN:	10:48 AM
MET WITH:	Robin Culver		TIME COMPLETED:	01:55 PM

ALLEGATION(S):

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Staff did not protect residents from getting scabies

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) LaQueena Lacy conducted an initial 10day complaint visit on 02/28/2022 to investigate the above allegation. LPA met with manager Brian Rosales and explained the purpose of the visit. LPA conducted a physical plant tour at 10:51am. It is alleged that multiple residents have scabies. To investigate the above allegation LPA began interviews with staff and administrator at 11:10am, interviews revealed that resident #1 (R1), one (01) out of four (04) residents in care was diagnosed with a potentially infectious disease. The facility was disinfected and deep cleaned by the facility maintenance guy (Wilbur Montonya). The furniture (couches and chairs) were disinfected, cleaned, and taken out of the house, all of the resident clothing was taken out of the facility and left in plastic trash bags zip tided in the garage for three (03) days. Robin Culver, and Brain Rosales conducted skin checks on (03) of the (04) residents on 01/28/2022 and they did not observe any bumps or rashes. Upon record review LPA observed R1s hospital discharge documents, R1 was diagnosed and treated for a potentially infectious disease at the hospital and received treatment 2xs with resolution.
Contiuned on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena Lacy	TELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20220218161853

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: EXCLUSIVE RAYA'S PARADISE, INC.	FACILITY NUMBER: 197607055
	VISIT DATE: 02/28/2022

NARRATIVE

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The facility took preventative measures to treat all residents for the potentially infectious disease, with a prescribed medication which was ordered on 02/17/2022 and 02/18/2022.
Based on information obtained through interviews, observation and record review, although the allegation may have happened or is valid, there is insufficient evidence to prove the violation did or did not occur, therefore the allegation is UNSUBSTANIATED.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena Lacy	TELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2022

LIC9099 (FAS) - (06/04)

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