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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608521
Report Date: 07/19/2024
Date Signed: 07/19/2024 01:11:36 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
01/03/2024 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 31-AS-20240103153651
FACILITY NAME:EXCLUSIVE RAYA'S PARADISE, INC.FACILITY NUMBER:
197608521
ADMINISTRATOR:MOTI MICHAEL GAMBURDFACILITY TYPE:
740
ADDRESS:852 N. SIERRA BONITA AVENUETELEPHONE:
(323) 782-1842
CITY:LOS ANGELESSTATE: CAZIP CODE:
90046
CAPACITY:6CENSUS: 6DATE:
07/19/2024
UNANNOUNCEDTIME BEGAN:
09:18 AM
MET WITH:Rocio Fonseca - StaffTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff are not trained appropriately to provide care to residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit at this facility to further investigate the above allegation. LPA met with staff Rocio Fonseca who called the administrator Brian Rosales and explained the reason for the visit. Mr. Rosales designated Ms. Fonseca to sign the report.

LPA conducted physical plant tour at 9:45 AM, requested copies of facility documents relevant to the investigation at 10:13 AM, reviewed facility documents from 10:30 AM to 11:30 AM and interviewed staff and resident between 12:00 PM to 12:45 PM. It was alleged that Staff who are present are allowed to start working without any training or prior experience. LPA's record review today at 10:30 AM revealed that all the staff present during visit on 01/05/24 and today have initial and yearly training record on file. LPA's interview with three (3) staff on 01/25/24 between 11:00 AM to 1:00 PM and today at 12:00 PM revealed that three (3) out of three (3) staff had undergone training before they started working and had a minimum eighty (80) hours on-the-job training/shadowing at the facility. (continued on LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024
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 2
Control Number 31-AS-20240103153651
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: 197608521
VISIT DATE: 07/19/2024
NARRATIVE
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(continued from LIC 9099)

Based on the information gathered during this and prior visit, the allegation is deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2