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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608745
Report Date: 05/21/2022
Date Signed: 05/21/2022 11:57:04 AM

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
01/06/2021 and conducted by Evaluator Tuesday Cabiness
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20210106162335
FACILITY NAME:PARADISE SENIOR LIVING -1FACILITY NUMBER:
197608745
ADMINISTRATOR:ANGELA ANGLE APOYANFACILITY TYPE:
740
ADDRESS:8435 AURA AVENUETELEPHONE:
(818) 626-3338
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY:6CENSUS: 6DATE:
05/21/2022
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Vanisa CampbellTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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1. Staff did not provide emergency responders information on resident
2. Staff were not knowledgeable of resident's medical conditions
3. Staff did not ensure that resident's oxygen needs were being met
4. Facility ran out of resident's oxygen
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tuesday Cabiness met with caregiver Vanisa Campbell, who was informed the reason of the visit. Administrator Angela Apoyan was contacted, and was also informed the reason of the visit. The following was determined:

Allegation # 1: Staff did not provide emergency responders information on resident
It was alleged that staff did not provide emergency responders information on resident. During the investigation, on 01/15/2021, 06/25/2021, 09/25/2021, 11/20/2021, 11/21/2021, and 12/02/2021, from various times, ranging from 8am to 4pm, LPA conducted interviews, and reviewed facility and resident records, pertaining to the complaint. It was reported by the Administrator to LPA, the facility staff called 911 for resident # 1 (R1) because of shortness of breath. The paramedics arrived and requested resident file and medical information. The Administrator confirmed that staff and the facility did not have resident records ready and
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2022
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 5
Control Number 31-AS-20210106162335
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: PARADISE SENIOR LIVING -1
FACILITY NUMBER: 197608745
VISIT DATE: 05/21/2022
NARRATIVE
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prepared for the emergency responders when requested. Administrator stated to LPA, that the paramedics were rushing staff and not social distancing during the pandemic, that staff panicked and could not prepare the documents in time. The only document provided for R1 was an identification card. It was revealed that the Administrator could not provide R1’s medical history, such as allergies, medications, or normal mental status. Although, the Administrator emailed the medical information to the hospital after R1 was transported, the facility did not have resident documents ready at the time of the request. This poses as a potential health and safety risk to residents in care. Therefore, the allegation “Staff did not provide emergency responders information on resident” is Substantiated.


Allegation # 2: Staff were not knowledgeable of resident's medical condition:
It was alleged that staff were not knowledgeable of resident’s medical condition. On 01/15/2021, 06/25/2021, 09/25/2021, 11/20/2021, 11/21/2021, and 12/02/2021, from various times, ranging from 8am to 4pm, LPA conducted interviews, and reviewed facility and resident records, pertaining to the complaint. According to information obtained, R1 was having difficulty breathing, and 911 was contacted to assist. Once the paramedics arrived, the facility did not have medical information to provide to the fire department. LPA requested the documents that was sent to the hospital and R1’s facility records, and upon review, it was revealed that the facility did not have a complete medical document for R1, nor did they provide Licensing documents, such as physician report, pre-appraisal, appraisal/need and service plan, or any other medical information for R1. R1 was admitted to the facility on 09/11/2019, and all resident documents should have been completed and prepared for medical professionals when requested. This poses as a potential health and safety risk to residents in care. Therefore, “Staff were not fully knowledgeable regarding R1’s medical condition”, and the allegation is Substantiated.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 31-AS-20210106162335
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: PARADISE SENIOR LIVING -1
FACILITY NUMBER: 197608745
VISIT DATE: 05/21/2022
NARRATIVE
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Allegation # 3: Staff did not ensure that resident's oxygen needs were being met:
It was alleged that staff did not ensure that resident’s oxygen needs were met. On 01/15/2021, 06/25/2021, 09/25/2021, 11/20/2021, 11/21/2021, and 12/02/2021from various times, ranging from 8am to 4pm, LPA conducted interviews, and reviewed facility and resident records, pertaining to the complaint. According to information obtained, 911 was contacted, due to R1`having shortness of breath and difficulty breathing. Upon arriving to the facility, it was reported it was reported to LPA, that the day of the 911 incident, the oxygen was delivered that day. But further information revealed, that when the paramedics and fire department arrived too the facility, R1’s oxygen mask was improperly applied on R1’s face, and the tank was empty. R1’s medical records revealed R1 had a diagnosis of pulmonary disease and low-flow oxygen should be used as needed. The facility was not monitoring R1 closely on oxygen use, and R1's tank was empty when paramedics arrived. This poses as a potential health and safety risk to residents in care. Therefore, the allegation “Staff did not ensure resident’s oxygen needs were met”, is Substantiated.

Allegation # 4: Facility ran out of resident's oxygen: It was alleged that facility ran out of resident’s oxygen. On 01/15/2021, 06/25/2021, 09/25/2021, 11/20/2021, 11/21/2021, and 12/02/2021, from various times, ranging from 8am to 4pm, LPA conducted interviews, and reviewed facility and resident records, pertaining to the complaint. According to information obtained, 911 was contacted, due to R1`having shortness of breath and difficulty breathing. Upon arriving to the facility, it was reported that R1’s difficulty of breathing, was caused by R1 running out of oxygen. It was reported LPA, that the day of the 911 incident, the oxygen was delivered that day. But further information revealed, that when the paramedics and fire department arrived too the facility, R1’s oxygen mask was improperly applied on R1’s face, and the tank was empty. The facility was not monitoring R1 closely on oxygen use, and R1's flow of oxygen was not properly being administered. This poses as a potential health and safety risk to residents in care. Therefore, it was determined the “Facility ran out of resident’s oxygen”, and the allegation is Substantiated.

Exit interview, copy of report, and appeal rights issued to Administrator.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 31-AS-20210106162335
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: PARADISE SENIOR LIVING -1
FACILITY NUMBER: 197608745
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/01/2022
Section Cited
CCR
87466
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Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning..This requirement was not met, evidenced by: based on
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Administrator agreed to submit in writing that facility staff will ensure that staff are properly trained when administering oxygen to residents in care.
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interviews, staff were not aware that R1 was having trouble breathing, and was not monitoring R1 closely on oxygen use. R1 ran out of oxygen. This is a potential health and safety risk to residents in care.
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Type B
06/01/2022
Section Cited
CCR
80070(a)
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Client Records; (a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client. This requirement was not met, evidenced by: based on the
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Administrator agreed to ensure that all medical and pertinent information be made available pertaining to residents when medical or any other professional request. A statement will be provided.
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admission from the Administrator, when paramedics arrived for R1, they did not have client or medical records available when requested. This poses as a potential health and safety risk to residents 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: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20210106162335
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: PARADISE SENIOR LIVING -1
FACILITY NUMBER: 197608745
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/01/2022
Section Cited
CCR
87618(5)
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(5) Ensuring that facility staff have knowledge of, and ability in the operation of the oxygen equipment. This requirement was not met, evidenced by: based on interviews it was revealed R1 had trouble
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Administrator agreed to submit in writing that staff are properly trained when administering oxygen to residents in care. And will provide training for future residents who are on oxygen.
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breathing, and when paramedics arrived, it was reported that R1's oxygen tank was empty and the mask was still connected to R1's face. This poses a potential health and safety risk to residents in care.
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Type B
06/01/2022
Section Cited
CCR
80075(h)
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Health Related Services: (h)There shall be at least one person capable of and responsible for communicating with emergency personnel in the facility at all times...shall be readily available:
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Administrator agreed to submit in writing that facility will have medical information availalbe when requested for medical or any other professional who request. Administrator will also
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This requirement was not met, evidenced by, staff did not have pertinent medical information to provide to paramedics for R1. This is a potential health and safety risk to residents in care
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ensure that at least (1) staff on duty is competent to communicate effectively. This statement will also be in writing.
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: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5