197609980-2-3-2023-29-AS-JAPL-CP3VAG-20230215151555

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609980
Report Date: 02/03/2023
Date Signed: 02/03/2023 02:06:10 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/01/2022 and conducted by Evaluator Sandra Urena

COMPLAINT CONTROL NUMBER: 29-AS-20221201105520

FACILITY NAME:	AMY'S PARADISE HOME OF ANGELS INC.		FACILITY NUMBER:	197609980
ADMINISTRATOR:	EMMA AVETISYAN		FACILITY TYPE:	740
ADDRESS:	11950 ROSCOE BLVD		TELEPHONE:	(310) 913-6161
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY:	6	CENSUS: 5	DATE:	02/03/2023
		UNANNOUNCED	TIME BEGAN:	10:05 AM
MET WITH:	Emma Elazyan		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility is placing residents on hospice that do not qualify.
Medications are not administered daily.

INVESTIGATION FINDINGS:

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On 02/03/2023, Licensing program Analyst (LPA) Sandra Urena, arrived unannounced for a subsequent complaint inspection for the allegations listed above. LPA Urena met with staff , and explained the reason for the visit. Staff called administrator Emma Avetisyan on the phone, and the LPA explained the reason for the visit. Ms. Avetisyan instructed staff Emma Elazyan to give the LPA tour of the facility, and to sign the report.

On 12/08/2022, Licensing program Analyst (LPA) Sandra Urena, arrived unannounced for an initial complaint inspection for the above allegations. The LPA met spoke with facility staff, and staff contacted the Administrator. The LPA spoke with the Administrator on the phone, and explained the reason for the visit. At 2:00 p.m., LPA Urena and the facility staff conducted a brief physical plant tour, interviewed administrator at 2:30 p.m. The LPA obtained documents for review pertinent to the investigation at 2:26 p.m. The LPA found that further investigation is needed before delivering the findings.
Continues on LIC 9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023

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 29-AS-20221201105520

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: AMY'S PARADISE HOME OF ANGELS INC.	FACILITY NUMBER: 197609980
	VISIT DATE: 02/03/2023

NARRATIVE

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On the allegation of ‘Facility is placing residents on hospice that do not qualify’, the complainant's concern is that residents that do not qualify for hospice services, are being served by a hospice agency. To investigate the allegation, LPA Urena conducted five (5) residents’ record review. The record review revealed that five out of five residents are not receiving hospice services. LPA Urena interviewed the Administrator, and the interview revealed that five out of the five residents are not receiving hospice services.

Based on the information obtained through record review, and interviews, there is insufficient evidence to support the allegation that facility is placing residents on hospice that do not qualify. Therefore, the allegation is deemed Unsubstantiated at this time.

On the allegation of ‘Medications are not administered daily’, the RP’s concern is that the medication is not being administered as prescribed. To investigate the allegation, LPA Urena conducted medication record review of the Medication Administration Record (MAR) and the medication containers. The record review of five out of five residents revealed that five out of five residents are being assisted with medication as prescribed by their physician. The MAR review was current as 02/03/2023. LPA Urena interviewed the staff, and the staff showed the LPA the medications for each resident, and how they assist residents with their medication.

Based on the information obtained through record review, and interviews, there is insufficient evidence to support the allegation that medications are not being administered daily. Therefore, the allegation is deemed Unsubstantiated at this time.

No deficiencies cited. Exit interview conducted, and a copy of the report was provided.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023

LIC9099 (FAS) - (06/04)

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