197608521-12-14-2024-31-AS-TAGD-DDBTLD-20250127134921

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608521
Report Date: 12/14/2024
Date Signed: 12/14/2024 02:58:07 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 Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20230816102458

FACILITY NAME:	EXCLUSIVE RAYA'S PARADISE, INC.		FACILITY NUMBER:	197608521
ADMINISTRATOR:	MOTI MICHAEL GAMBURD		FACILITY TYPE:	740
ADDRESS:	852 N. SIERRA BONITA AVENUE		TELEPHONE:	(323) 782-1842
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90046
CAPACITY:	6	CENSUS: 5	DATE:	12/14/2024
		UNANNOUNCED	TIME BEGAN:	09:12 AM
MET WITH:	Rocio Fonseca - Staff		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff speak inappropriately to residents.
Staff left resident soiled for an extended period of time.
Staff did not seek timely medical attention for a resident.
Staff handled resident roughly.
Resident sustained unexplained bruises while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) conducted an unannounced subsequent complaint visit at this facility to further investigate the above allegations. LPA met with Rocia Fonseca and explained the reason for the visit.

LPA conducted physical plant tour at 9:34 AM, requested copies of facility documents relevant to the investigation at 10:00 AM, reviewed records between 10:15 AM to 11:15 AM and interviewed staff and residents between 11:15 AM to 1:35 PM. Regarding the allegation that Staff speak inappropriately to residents, it was alleged that Staff #1 (S1) was rude Residents #1 (R1) and Resident #2 (R2). LPA's inteview with two (2) staff present today who worked with S1 beween 11:15 AM to 1:35 PM today revealed that they did not witness S1 being rude or speak inappropriately to any resident at the facility while working at the facility. LPA's interview with Resident #3 (R3) or the only aware resident of the facility today also revealed that R3 did not witness S1 or any staff being rude or speak inappropriately to R3 or any resident of the facility. LPA attempted to interview the other four (4) residents but one (1) out of four (4) resident was asleep during the visit and the other three (3) are diagnosed with Dementia. (continued on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2024

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-20230816102458

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: 12/14/2024

NARRATIVE

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(continued from LIC 9099)

Regarding the allegation that Staff left resident soiled for an extended period of time, it was alleged that Staff left R3 soiled for an extended period of time. LPA's record review today between 10:15 AM to 11:15 AM revealed that R3 is not incontinent both bladder and bowel but needed assistance with toileting. LPA's interview staff today revealed that they assist R3 to change and dress only in the morning upon getting up. Further, R3 is aware and would call for help when R3 needed one. LPA observed a bell beside R3's bed that R3 used to call for assistance. LPA's interview with R3 today confirmed that staff check on R3 regularly whole day round.

Regarding the allegation that Resident sustained unexplained bruises while in care, it was alleged that Resident #4 (R4) had multiple bruises while living at the facility. LPA's record review today revealed that R3 in on blood thinners and easily get bruised. LPA also observed that R3 had multiple small bruises on R3's arm. LPA's interview with R3's family member today revealed that they are aware of R3's condition and are not worried about it because facility staff always report to them regularly as to the condition of R3.

Regarding the allegation that Staff handled resident roughly, it was alleged that S1 physically jerks R1 when moving R1 around. LPA's record review today revealed that R1 is non-ambulatory but LPA observed during today's visit revealed that R1 was able to ambulate on R1's own. LPA's interview with staff today revealed that R1 only need assistance to get up from sitting too long but not to ambulate. Further interview with staff also revealed that they did not witness S1 jerking or being rough with R1 in anyway. LPA's interview with R3 or the only aware resident of the facility also revealed that R3 did not witness any staff jerking or being rough to any resident at the facility.

Regarding the allegation that Staff did not seek timely medical attention for a resident, it was alleged that R4 had a foul smell coming from R4 which the Reporting Party (RP) thinks that R4 has an infection somewhere that is not being treated appropriately. LPA's record review today revealed that R1 did not have any recorded infection in 2023 and the last hospital visit was 08/02/23 for other medical condition not related to any kind of infection. LPA's interview with R4's family member today revealed that they did not smell R4 nor reported to have an infection while living at the facility. Based on the information gathered during this and prior visit, the allegations are 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: 12/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2024

LIC9099 (FAS) - (06/04)

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