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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608745
Report Date: 09/08/2023
Date Signed: 09/08/2023 02:14:19 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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
09/01/2023 and conducted by Evaluator Mariana Agban
COMPLAINT CONTROL NUMBER: 31-AS-20230901102426
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: 4DATE:
09/08/2023
UNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Angela Apoyan-AdministratorTIME COMPLETED:
02:20 PM
ALLEGATION(S):
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Licensee did not provide proper notification of rate increase.
INVESTIGATION FINDINGS:
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On 09/08/23 Licensing Program Analysts (LPAs) Mariana Agban, Michael Cava, Chris Alemoh and Leslie Ngo- Castaneda conducted an unannounced intial complaint visit for the above allegation.
LPAs arrived at the facility and were granted access by staff. Administrator arrived shortly after and LPAs explained the reason for the visit. During the course of the investigation, interview and record review was made. At 11:50 AM, LPA team conducted a physical plan tour, to ensure health and safety of the clients are protected and is in compliance with Title 22 Regulations. At 12:30 PM, LPA team requested copies of pertinent infomation which include, but not limited to Physician's Report, Appraisal Needs and Services Plan, Individual Program Plan (IPP), etc., relevent to the investigation.

Allegation: Licensee did not provide proper notification of rate increase.
It was alleged that R1 had a rate increase in May 2023 and or June 2023. Administrator admit that they failed to provide a written notification for rate increase.
(Continue on 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023
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-20230901102426
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PARADISE SENIOR LIVING -1
FACILITY NUMBER: 197608745
VISIT DATE: 09/08/2023
NARRATIVE
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Administrator stated that R1 resign at shared bedroom and as R1 living of care increased, Administrator provided a private room to R1 with a higher rate. Administrator stated that R1 was aware of the increase and he verbally agreed. During the course of investigation, LPAs conduct a file review and didn't observe any records showing the rate increase. Based on information obtained, this allegation deemed Substantiated. Citation on issued on LIC9099 D. Exit interview conducted and copy of this report issued.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 31-AS-20230901102426
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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: 09/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/15/2023
Section Cited
HSC
1569.655(a)
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(a) If a licensee of a residential care facility for the elderly increases the rates of fees for residents or makes increases in any of its rate structures for services, the licensee shall provide no less than 60 days' prior written notice to the residents or the residents' representatives setting forth the amount of the increase, the reason for the increase, and a general description of the additional costs, except for an increase in the rate due to a change in the level of care of the resident.
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As POC, the administrator agrees to review this section of the Health and Safety Code and self certify that they've read and understood this section. This self certification is due to the licensing agency no later than 09/15/23.
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The Administrator failed to provide a written notification of the rate increase. This is potenial health and safety for the 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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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
09/01/2023 and conducted by Evaluator Mariana Agban
COMPLAINT CONTROL NUMBER: 31-AS-20230901102426

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: 4DATE:
09/08/2023
UNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Angela Apoyan-AdministratorTIME COMPLETED:
02:20 PM
ALLEGATION(S):
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Facility staff restrained resident in care.
INVESTIGATION FINDINGS:
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On 09/08/23 Licensing Program Analysts (LPAs) Mariana Agban, Michael Cava, Chris Alemoh and Leslie Ngo- Castaneda conducted an unannounced intial complaint visit for the above allegations.
LPAs arrived at the facility and were granted access by staff. Administrator arrived shortly after and LPAs explained the reason for the visit. During the course of the investigation, interview and record review was made. At 11:50 AM, LPA team conducted a physical plan tour, to ensure health and safety of the clients are protected and is in compliance with Title 22 Regulations. At 12:30 PM, LPA team requested copies of pertinent infomation which include, but not limited to Physician's Report, Appraisal Needs and Services Plan, Individual Program Plan (IPP), etc., relevent to the investigation.

Allegation: Facility staff restrained resident in care.
It was alleged that on or around 5-15-23 that resident was observed to have guardrails up and chairs surronding their bed to restrain the resident due symptoms which resulted from facility staff not giving the (Continue on 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20230901102426
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PARADISE SENIOR LIVING -1
FACILITY NUMBER: 197608745
VISIT DATE: 09/08/2023
NARRATIVE
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resident their medications for 6 days. LPAs interviewed 4 out 4 residents and they denied the allegation. Residents stated that they haven't experienced any restraining from facility staff during their stay. Furthermore, each residents stated that their needs are being met, including, but not limited to medication management. Interview with Administrator revealed that they haven't observe or heard any complaints from residents regarding staff restraining residents. Administrator denied the allegation. In addition to interviews, LPAs conducted a record review of the Resident 1's (R1) Centrally Stored Medication and Destruction Record for May 2023. Although R1's medications were no longer at the facility, as R1 moved out on or around July 24, 2023, there were no discrepancies observed on the Centrally Stored Medication Record. Based on information obtained, it could no be proven that staff restrained a resident in care. Therefore, the allegation is deemed Unsubstantiated at this time.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5