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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608521
Report Date: 04/21/2022
Date Signed: 04/21/2022 06:15:20 PM

Substantiated


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
04/13/2022 and conducted by Evaluator LaQueena Lacy
COMPLAINT CONTROL NUMBER: 31-AS-20220413095101
FACILITY NAME:EXCLUSIVE RAYA'S PARADISE, INC.FACILITY NUMBER:
197608521
ADMINISTRATOR:MOTI MICHAEL GAMBURDFACILITY TYPE:
740
ADDRESS:852 N. SIERRA BONITA AVENUETELEPHONE:
(323) 528-3436
CITY:LOS ANGELESSTATE: CAZIP CODE:
90046
CAPACITY:6CENSUS: 5DATE:
04/21/2022
UNANNOUNCEDTIME BEGAN:
10:38 AM
MET WITH:Robin CulverTIME COMPLETED:
03:53 PM
ALLEGATION(S):
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Resident eloped from the facility.
Staff did not report resident's AWOL
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) LaQueena Lacy conducted an initial 10day complaint visit to investigate the above allegation. LPA met with staff Rocio and explained the purpose of the visit. It is alleged that resident #1 R1 eloped from the facility and was found and brought back to the facility by the police. To investigate the above allegation LPA conducted a physical plant tour at 10:45am. LPA began interviews with Robin Executive Director (ED) and staff at 11:15am between 12:25pm. ED and staff deny that the police bought R1 back to the facility. Interviews revealed that R1 left the facility unassisted and was located by staff at the sister facility property Exclusive Raya’s Paradise, INC located at 849 N Gardner St. Los Angeles, CA 90046, in the driveway near the gated fence. The four (4) properties backyards are adjoined together and not sectioned or blocked off by any fencing. Staff confirmed they did not hear any alarms go off in the morning R1 was found outside the facility. Staff had no knowledge how R1 left the facility and why the alarm did not go off. During the investigation LPA observed R1 wearing an ankle alarm that is triggered if R1 passes the sensors that are located outside in the bushes near the front gate of the properties.
Continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena LacyTELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022
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 4
Control Number 31-AS-20220413095101
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: 197608521
VISIT DATE: 04/21/2022
NARRATIVE
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Upon inspection of the facility, LPA observed that the facility has different type of alarms on main entrance and all other exit doors. A main door alarm that sounds whenever a door is opened or closed cannot be turned off manually and staff could not explain how R1 left and which exit door was used.
A review of records conducted at 12:15pm revealed that R1 is diagnosed with Dementia and leaving the facility unassisted may pose a hazard to R1’s health and safety. Due to health conditions and medical diagnoses, R1 has wandering behaviors.
Based on inspection, observation and interviews, there is sufficient information to support the allegation. Therefore, allegation is deemed SUBSTANTIATED at this time.


Staff did not report resident's AWOL

To investigate the above allegation, LPA conducted an interview with ED and it was confirmed that the facility did not report the incident to Community Care Licensing (CCL) because “they didn’t consider an incident of elopement because R1 was found on the property. Upon record review conducted at 12:15pm, R1 is not able to leave the facility unassisted. Based on LPAs Inspection and observation, R1 was found unassisted outside of the property line at Exclusive Raya’s Paradise, INC located at 849 N Gardner St. Los Angeles, CA 90046, which has a different address. The incident could pose a hazard to R1’s health and safety. Therefore, it should have been reported to the Licensing Office.
Based on observations, and record review, there is sufficient information to support the allegation. Therefore, allegation is deemed SUBSTANTIATED at this time.

Exit interview conducted, Deficiencies cited, copy of report and appeal rights issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena LacyTELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20220413095101
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: 197608521
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
05/01/2022
Section Cited
CCR
87211(a)(1)(D)
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87211Reporting Requirement(a) Each licensee shall furnish to the licensing agency...(1)A written report shall be submitted...within seven days of the occurrence...(D)Any incident which threatens the welfare, safety or health of any resident...This requirements is not met as evidenced by:

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Licensee will review title 22 regarding reporting requirements. Will provide in-service and submit to LPA by POC due date.
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Based on observations, and interviews the facility failed to report that R1 was found outside the facility unassisted in the driveway of property 849 N. Gardner St. This may pose a potential Health and Safety risk to clients in care.
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Request Denied
Type B
05/01/2022
Section Cited
CCR
87705(k)(8)
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87705 Care of Persons with Dementia (k) The following initial and continuing requirements must be met for the licensee...(8)Delayed egress devices shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents...This requirement is not met as evidenced by:
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Licesnee will review title 22, provide in-service for care of person with dementia, and submit to LPA by due POC due date.
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Based on interviews, observations and record review, the facility did not ensure not to subsitite sufficient quantity of qualified personnel. This may pose 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: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena LacyTELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 31-AS-20220413095101
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: 197608521
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
05/01/2022
Section Cited
CCR
87464(d)
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87464 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 as identified in the pre-admission appraisal... This requirement is not met as evidenced by:
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Licensee will provide an in-service to ensure that all alarms are on and that residents are observed 24 hours a day. Licensee will submit in-service to LPA by POC due date.
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Based on interviews, observations and record review, the licensee did not ensure that R1 was assisted while leaveing the facility. This may pose 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: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena LacyTELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4