197609494-8-24-2023-31-AS-NMAN-CY7QZS-20231204113713

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609494
Report Date: 08/24/2023
Date Signed: 08/24/2023 02:28:09 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
02/14/2023 and conducted by Evaluator Nicholas Reed

COMPLAINT CONTROL NUMBER: 31-AS-20230214122636

FACILITY NAME:	RAYA'S PARADISE, INC.		FACILITY NUMBER:	197609494
ADMINISTRATOR:	GAMBURD, MOTI		FACILITY TYPE:	740
ADDRESS:	846-848 N. SIERRA BONITA AVE.		TELEPHONE:	(323) 851-7515
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90046
CAPACITY:	11	CENSUS: 9	DATE:	08/24/2023
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Brian Rosales		TIME COMPLETED:	02:25 PM

ALLEGATION(S):

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Resident sustained an unexplained fracture while in care.

INVESTIGATION FINDINGS:

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At 1:00 p.m. on 08/24/2023, Licensing Program Analyst (LPA) Nicholas Reed made an unannounced subsequent visit to complete an investigation of the above noted allegation. LPA met with Executive Director Brian Rosales and disclosed the reason for the visit.

Regarding the allegation “Resident sustained an unexplained fracture while in care”, it was alleged that on 02/28/2022 around 8:00am, Resident #1 (R1) complained of severe pain in their arm to the private aid. R1’s arm was observed to be slightly swollen, and the skin around the upper torso and right arm was warm. It was not clear when and how R1 was injured.

The investigation was conducted by the LPA Nicholas Reed and Senior Investigator from the Investigations Bureau Hector Edward.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20230214122636

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: RAYA'S PARADISE, INC.	FACILITY NUMBER: 197609494
	VISIT DATE: 08/24/2023

NARRATIVE

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On 02/12/2023, at 3:30pm, LPA Reed briefly spoke with facility staff and R1. At 3:40pm, LPA requested facility records. On 03/02/23 between 10:55am and 1:30pm, Investigator Edward spoke with the Executive Director (ED), facility nurse, and other facility staff and reviewed facility records relevant to investigation. Records included but were not limited to R1’s physician report, Needs and Service Plan, facility internal incident log, copies of incident reports involving R1, and other documents.

Information received revealed that staff utilize a Hoyer Lift to assist R1. On 02/28/2023, at 4:00am, S1 attended R1 for incontinent care. While changing R1, S1 did not use the Hoyer Lift. R1 slid down the bed and was about to fall. To prevent the fall, S1 grabbed R1 by their right arm “between the shoulder and the elbow" and assisted R1 to the ground. To assist R1 back to bed, S1 called Staff #2 (S2) from the facility next door to help. S1 and S2 used a Hoyer lift and transferred R1 back to bed. No body assessment was performed prior to putting R1 to bed. Interviews revealed that the incident was not documented or reported by S1 or S2 and between 4:00am and 8:30am. R1 was not attended to by S1 or other morning shift staff.

On or around 8:30am, R1’s private aid arrived at the facility and observed R1 to be in pain with a swollen right arm. The private aid informed facility staff, and they reported to the facility nurse. The follow up actions were taken by the facility staff on or around 9:30am.

Overall information gathered from the documents supported the information revealed from interviews.
Based on inspection, observation, interviews, and record review, there is sufficient information to conclude that R1 sustained injuries due to improper assistance. Therefore, the allegation is SUBSTANTIATED at this time.

Exit interview conducted. Appeal rights discussed. Copy of report provided.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 31-AS-20230214122636

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: RAYA'S PARADISE, INC.	FACILITY NUMBER: 197609494
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/24/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 08/29/2023 Section Cited CCR 87464(d)	1 2 3 4 5 6 7	87464 Basic Services (d) if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs ... and providing the other basic services. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee will provide an in-service training and show proof of correction by the due date.
	8 9 10 11 12 13 14	Based on observations, interviews, and record review, the licensee did not comply with the section cited above with 1 resident which posed an immediate Health, Safety or Personal Rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023

LIC9099 (FAS) - (06/04)

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