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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609312
Report Date: 12/19/2023
Date Signed: 12/19/2023 02:21:57 PM


Document Has Been Signed on 12/19/2023 02:21 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:A PARADISE IN THE VALLEYFACILITY NUMBER:
197609312
ADMINISTRATOR:DER-APRAHAMIAN, ARSENFACILITY TYPE:
740
ADDRESS:7754 TEXHOMA AVETELEPHONE:
(323) 821-1419
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY:6CENSUS: 3DATE:
12/19/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Arsen Der-AprahamianTIME COMPLETED:
02:25 PM
NARRATIVE
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Licensing Program Analysts (LPAs), Tihesha Smith and Gina Saucedo conducted a case management visit in conjunction with a complaint visit at this facility.

Licensing staff conducted a tour of the physical plant at approximately 10:05 am and reviewed resident and facility records.

LPA Smith discussion with Administrator at approximately 11:15 am revealed that no changes or corrections deficiencies noted during visit on 9/28/23 have been addressed. Administrator states have obtained an agreement with a contractor. LPA requested a copy and Administrator emailed copy to email LPA Smith.



Deficiencies are cited and noted on LIC 809D.

Exit interview conducted, appeals, and copy of report provided.















SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha SmithTELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/19/2023 02:21 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: A PARADISE IN THE VALLEY
FACILITY NUMBER: 197609312

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/22/2023
Section Cited
CCR
87307(a)

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7307(a) Personal Accommodations and Services. Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility.
This requirement is not met as evidenced by:
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With in 24 hours the Licensee will provide written documentation certifying that no individual will be living/sleeping in the storage room or other areas on the property that does not have approved permits from appropriate government agencies. Remove bed or provide documentation that areas previously discussed are not apart
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Based on physical plant inspection Licensing staff observed: bed in storage room, staff accommodations in room identified as a garage, and staff room in ADU structure area which is not designated as staff rooms in the plan of operation or on facility sketch.
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of the facilities. Poc due date:12/22/2023
Type A
12/20/2023
Section Cited
CCR87608(a)(3)

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A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.
This requirement is not met as evidenced by:
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The Licensee/Administrator will contact resident physicians to obtained required medical documentation for postural supports. POC due date:12/20/23
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Based on observation the licensee failed to ensure that Resident has a written order for postural support placed on Residents bed. This poses an immediate health and safety risk to 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: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha SmithTELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2023
LIC809 (FAS) - (06/04)
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