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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609316
Report Date: 10/22/2020
Date Signed: 10/22/2020 03:50:56 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/12/2020 and conducted by Evaluator Ulysses Coronel
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20201012164530
FACILITY NAME:PARADISEFACILITY NUMBER:
197609316
ADMINISTRATOR:RAFIA, BAHMANFACILITY TYPE:
740
ADDRESS:1931 PREUSS ROADTELEPHONE:
(310) 876-1293
CITY:LOS ANGELESSTATE: CAZIP CODE:
90034
CAPACITY:6CENSUS: 6DATE:
10/22/2020
UNANNOUNCEDTIME BEGAN:
08:49 AM
MET WITH:Shimmy BayarTIME COMPLETED:
04:05 PM
ALLEGATION(S):
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Resident caused injury to another resident in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ulysses Coronel initiated a complaint investigation for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Eliat Nahum, the facility staff.

The investigation consisted of the following: On 10/22/2020 LPA Coronel conducted telephonic interviews with facility administrator Shimmy Bayar, facility staff's S1 & S2 and residents R1 and R2. A video call which consisted of a review of the physical plant which includes the backyard, kitchen, living room and resident bedrooms was also conducted. LPA also conducted a review of the facility's Unusual Incident/Injury Report dated 10/12/2020.

The investigation revealed the following: On 10/22/2020 LPA conducted virtual tour of the facility and obseved that R1 and R2 were roommates. On 10/22/2020 LPA reviewed Unusual Incident/Injury Report dated 10/12/2020, LPA observed administrators comments that R1 displayed prior agressive behaviors towards R2 on 09/15/2020 and 09/24/2020.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2020
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 3
Control Number 11-AS-20201012164530
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: PARADISE
FACILITY NUMBER: 197609316
VISIT DATE: 10/22/2020
NARRATIVE
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On 10/22/2020 S1 stated that R1 keeps on calling R2 names and that the facility is in the process of relocating R2 to another facility. On 10/22/2020 S2 said that R1 gets very demanding of the people around them including other residents and would get very aggressive when they do not get their way and also stated that "R1 would initiate arguments with R2 every 3 to 5 days demanding that R2 do things for R1 like tying R1's shoes or turning of the light switches for R1, On 10/07/2020 around 9:00 am, I gave R1 Tylenol for their pain. S2 added that "R1 was seated from the other side of the living room and suddenly grabbed the remote from R2's hand, R1 repeatedly called R2 Nword, then R2 struck R1 in the face. I told R1 not to say that again..." On 10/22/2020 R1 was not able to provide coherent answers to LPA, LPA observed S1 shaking their head and LPA stopped the interview. On 10/22/2020 R2 stated that "My roommate has been bothering me since I got here, about 6 months ago." and "R2 is making threats like "I'll F you up", "I dont want you to be here, I'll have you removed." and calls me using racial slurs." Regarding the allegation "Resident caused injury to another resident in care." Based on LPA’s observations, interviews and record reviews, the preponderance of evidence standard has been met therefore the above allegation is found to be substantiated. California Code of Regulations, Tittle 22 are being cited please see LIC9099-D.

A telephonic exit interview was conducted, Plans of Corrections were reviewed and developed with Administrator Shimmy Bayar. A copy of this report and appeal rights were discussed and a hard copy was provided via email for signature.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20201012164530
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: PARADISE
FACILITY NUMBER: 197609316
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/26/2020
Section Cited
CCR
87468.1(a)(3)
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87468.1 Personal Rights of Residents in All Facilities(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement was not met as evidenced by:
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Administrator agrees to submit a writte plan of corection to LPA by POC Due date. Administrator plans to transfer R2 immediately to another licensed facility and conduct a meeting with R1's family to create a plan and obtain services to address R1's behavioral needs.
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Based on LPA observation, interviews and record review the licensee failed to ensure that esidents are accorded safe, healthful and comfortable accommodations which poses a potential risk to the health and safety of 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: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 3