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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608745
Report Date: 09/21/2023
Date Signed: 09/21/2023 01:38:11 PM

Unsubstantiated


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
08/29/2023 and conducted by Evaluator Mariana Agban
COMPLAINT CONTROL NUMBER: 31-AS-20230829161527
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: 3DATE:
09/21/2023
UNANNOUNCEDTIME BEGAN:
12:26 PM
MET WITH:Helen Ichmelyan- CaregiverTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff did not provide resident's authorized representative with an incident report
Staff did not provide resident's records to resident's authorized representative
INVESTIGATION FINDINGS:
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On 09/21/23 Licensing Program Analysts (LPAs) Mariana Agban and Michael Cava conducted an unannounced subsequent complaint visit for the above allegation. LPAs arrived at the facility and were granted access by staff. LPAs communicated with the Administrator through telephone to explain the reason of the visit. Administrator was unable to join this visit because they took one of the residents to their doctor appointment.

Allegation: Staff did not provide resident's authorized representative with an incident report
It was alleged that staff failed to provide an incident report on or around July 24,2023 for reporting resident's fall. During the records reviews, LPAs obtain the incident report for R1's fall on July 24,2023. Interview with the Administrator revealed that LIC 624 Incident Report was sent on 08/31/23 to R1's POA via email.LPAs obtain a copy of the Administrator's email communication with R1's POA confirming that an incident report was sent to them on 08/31/23. Therefore based on this information, the allegation can't be proven. Allegation is deemed unsubstantiated at this time. (Continue on 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023
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 2
Control Number 31-AS-20230829161527
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: 09/21/2023
NARRATIVE
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Allegation: Staff did not provide resident's records to resident's authorized representative

It was alleged that staff failed to provide LIC 622 Centrally Stored Medication Destruction Record to R1's POA requested. During the records reviews, LPAs obtain Centrally Stored Medication Destruction Record showing the current medication list at the time. LPAs obtain a copy of the Administrator's email communication with R1's POA confirming that Centrally Stored medication Destruction Record was sent to them on 08/31/23. Therefore, based on this information, the allegation can't be proven. Allegation is deemed unsubstantiated at this time.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2