197607979-2-1-2024-31-AS-NMAN-D6JPDH-20240624111332

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607979
Report Date: 02/01/2024
Date Signed: 02/01/2024 01:52:25 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
08/16/2023 and conducted by Evaluator Nicholas Reed

COMPLAINT CONTROL NUMBER: 31-AS-20230816102737

FACILITY NAME:	EXCLUSIVE RAYA'S PARADISE, INC.		FACILITY NUMBER:	197607979
ADMINISTRATOR:	MICHAEL GAMBURD		FACILITY TYPE:	740
ADDRESS:	851 N. GARDNER STREET		TELEPHONE:	(323) 951-0598
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90046
CAPACITY:	4	CENSUS: 3	DATE:	02/01/2024
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Brian Rosales		TIME COMPLETED:	01:55 PM

ALLEGATION(S):

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Resident sustained unexplained bruises while in care
Staff do not ensure facility is clean
Staff left resident soiled for an extended period of time
Staff overmedicated residents
Staff are mismanaging residents’ medication

INVESTIGATION FINDINGS:

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At 12:30 p.m. on 02/01/2024, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with Administrator and disclosed the reason for the visit.

To investigate the allegation above, LPA conducted an initial visit on 08/24/2023 and toured the facility inside and out at 12:15 p.m. and conducted a record review at 1:00 p.m. including but not limited to the resident list, staff list, admission agreements, physician reports, care plans, and care notes. LPA interviewed the administrator at 12:30 p.m. on 11/16/23, Staff #1 (S1) at 1:00 p.m. on 11/16/23, Staff # (S2) at 4:00 p.m. on 01/23/24, Staff #3 (S3) at 4:15 p.m. on 01/23/24, and Staff #4 (S4) at 2:30 p.m. on 01/29/24. LPA conducted a subsequent visit today and conducted a medication review at 12:50 p.m., interviewed Resident #3 (R3) at 1:10 p.m., and Staff #5 (S5) at 1:25 p.m., and toured the facility at 1:15 p.m.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024

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 3

Control Number 31-AS-20230816102737

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: EXCLUSIVE RAYA'S PARADISE, INC.	FACILITY NUMBER: 197607979
	VISIT DATE: 02/01/2024

NARRATIVE

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***This page was amended to include additional pertinent information *** - LPA Reed, 10:20 a.m., 06/21/24
Regarding the allegation “Resident sustained unexplained bruises while in care” it was alleged that staff did not know how Resident #1 (R1) had gotten bruises on their chin, abdomen, and arms. Also, R1 stated someone was attacking them. R1 was unavailable for interview. Interview with the administrator revealed they were not aware of any bruises on R1, and R1 occasionally spoke incoherently. No instances of R1 being attacked were reported to the administrator. Interview with S1 revealed R1 had some difficulty with mobility, and staff supported R1’s needs for mobility assistance by following R1 when they are outside of their room. Injuries on R1’s chin may have been resulted from a fall. However, no recent falls were reported to S1. Three (03) out of the three (03) other staff interviewed were not aware of any reports of R1 being attacked or any bruising. Record review revealed that R1 was prone to wandering, confusion, and some visual impairment. R1’s care plan noted they were a low fall risk. Internal daily log for R1 did not reveal any information to verify the allegation. There were no reports of bruising on R1’s chin, abdomen or arms or any reports of R1 being attacked. Based on interviews and record review, R1 may have suffered from fall resulting bruises. However, there is not sufficient information to verify the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.
Regarding the allegation “Staff do not ensure facility is clean” it was alleged the bathroom had feces on the wall and the floors were covered in trash. Facility tours on 08/24/2023 and today revealed no signs of trash or feces in the facility. The resident bathroom was sanitary, and no hazards were observed. S2, S3, and S4 all confirmed that they were not aware of any feces in bathrooms or trash on floors. S2 stated when staff are not attending to residents, they are trained to maintain the facility in an orderly manner. Staff clean unsanitary conditions “right away”. R3 stated the facility is clean to their liking and they have not seen feces in the bathroom. LPA observed staff sweeping the main entrance around 12:45 p.m. today. Based on interviews and observations, the staff have ensured the facility was clean. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.
Regarding the allegation “Staff left resident soiled for an extended period of time” it was alleged staff do not change Resident #2 (R2) enough which led to multiple Urinary Tract Infections (UTIs). Record review revealed R2 experienced bowel and bladder impairment. R2’s care plan stated they required “extensive” and “total” assistance with toileting. R2’s care notes revealed staff routinely assisted with showering, grooming, and toileting. S1 stated R2’s UTIs may have been caused by their lack of hydration as R2 often refused staff assistance. S2 and S4 noted R2 was never left in a soiled diaper, and they checked R2’s diapers every 2 hours and changed them if needed. Based on interviews and record review, staff did not leave R2 in soiled diapers. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 31-AS-20230816102737

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: EXCLUSIVE RAYA'S PARADISE, INC.	FACILITY NUMBER: 197607979
	VISIT DATE: 02/01/2024

NARRATIVE

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Regarding the allegation “Staff overmedicated residents” it was alleged Staff #5 (S5) was overheard claiming they overmedicate residents. Interview with S5 revealed they were a nurse but rarely assist with medications at the facility. They have never overmedicated a resident or mismanaged medication. Interview with the administrator and four (04) out of four (04) other staff revealed they had never heard S5 say anything regarding overmedicating residents. S3 stated S5 trained them on medication procedures and was a credentialed nurse. S4 confirmed S5 was a Certified Nursing Assistant (CNA) and was “on top of it” and “the best”. R3 stated they have never been overmedicated or had any medication issues. Based on interviews, S5 has not overmedicated residents. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

Regarding the allegation “Staff are mismanaging residents’ medication” it was alleged some Norco medications were missing. LPA and the administrator completed a medication review and noted all Norco medications were accounted for. Interviews with the administrator and five (05) out of five (05) staff revealed they were unaware of any missing medications. S3 stated they had never assisted with Norcos and staff are trained to have hospice nurses or a supervisor assist with Norco medications. Based on interviews and observations, staff are not mismanaging resident medications. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

No immediate health and safety hazards were observed during this visit.

Exit interview conducted. Appeal rights discussed. Copy of report provided.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024

LIC9099 (FAS) - (06/04)

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