197609494-2-1-2024-31-AS-NMAN-D27W43-20240206155653

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609494
Report Date: 02/01/2024
Date Signed: 02/01/2024 01:41:29 PM

Unsubstantiated

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
02/13/2023 and conducted by Evaluator Nicholas Reed

COMPLAINT CONTROL NUMBER: 31-AS-20230213085222

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: 7	DATE:	02/01/2024
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Brian Rosales		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Facility staff did not allow resident to have visitors.
Facility staff did not ensure that resident was fed.
Facility staff did not ensure that resident was taking their medications.
Staff did not attend the residents as required.

INVESTIGATION FINDINGS:

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At 12:30 p.m. on 02/01/2024, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with Administrator and disclosed the reason for the visit.

To investigate the allegations above, LPA conducted an initial visit on 02/14/2023 and reviewed pertinent records at 3:40 p.m. including but not limited to the resident list, staff list, admission agreement, and care notes, and interviewed the administrator at 4:00 p.m. LPA interviewed Staff #1 (S1) at 1:00 p.m. on 11/16/23, Staff #2 (S2) at 4:15 p.m. on 01/23/24, and Staff #3 (S3) at 2:30 p.m. on 01/29/24. LPA conducted a subsequent visit today and toured the facility at 12:45 p.m.

Regarding the allegation ”Facility staff did not allow resident to have visitors” it was alleged that S1 told the family of Resident #1 (R1) they were not allowed to visit. Interview with S1 revealed they informed family of R1’s health status but never told visitors they could not come to the facility.

Unsubstantiated

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: 02/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024

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 31-AS-20230213085222

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: 02/01/2024

NARRATIVE

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S1 further stated that R1’s family visited several times, but they did not follow the facility’s safety protocols. The Administrator also confirmed that the facility followed the Centers for Disease Control (CDC) guidance and the mitigation plan regarding facility visitation. Visitation was allowed but limited to protect the health of all facility residents. Record review revealed the facility’s mitigation plan had a visitation policy in place. Additionally, visitors could call ahead for “visiting tips”. Care notes revealed R1 did have a visitor on 11/26/2022. Staff interviewed confirmed the facility followed the visitation policy listed on the mitigation plan and were not aware of any issues with visitation. Based on interviews and record review, the facility staff allowed R1 to have visitors. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

Regarding the allegation ”Facility staff did not ensure that resident was fed” it was alleged facility staff did not encourage R1 to eat despite their deteriorating health. Review of care notes revealed R1 ate 50% - 100% of their meals in November 2022. Staff supplemented R1’s diet with snacks and nutritional shakes. R1 ate less than 50% of their meals in December 2022. Interview with the administrator revealed staff encouraged R1 to eat, but R1 would store food in their mouth and spit it out when staff were not looking. S1 confirmed R1 would store food instead of eating it. S2 and S3 stated R1 ate all their food. Based on interviews and record review, the facility provided R1 with meals and supplemental shakes to ensure they were fed. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

Regarding the allegation ”Facility staff did not ensure that resident was taking their medications” it was alleged that R1 was not taking their medications. Interview with the administrator revealed that R1 took all of their regular medications, however R1’s hospice agency frequently changed R1’s medications. S1 noted R1 had difficulty swallowing but took all of their medications. S2 and S3 could not recall any missed or refused medications. Record review did not reveal any information regarding missed or refused medications either. Based on interviews and record review, the facility ensured R1 was able to take all medications. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

Regarding the allegation ”Staff did not attend the residents as required” it was alleged staff left R1 unsupervised for fear of contracting R1’s illness. Interview with S2 and S3 revealed they attended to R1 regularly during R1’s admission. S3 “took good care of” R1. Record review of care notes revealed staff regularly provided meals, supervision, and assistance with grooming, and S2 checked on R1 every 2 hours. Other staff were noted to check on R1 every hour. Interview with the administrator revealed staff assisted with changing, grooming, and medications regularly.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20230213085222

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: 02/01/2024

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	S1 noted staff wore protective gear and attended trainings to provide increased supervision for R1. Based on interviews and record review, the facility attended R1 as required. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health and safety hazards were observed during this visit. 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: 02/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024

LIC9099 (FAS) - (06/04)

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