197609982-11-18-2022-29-AS-JAPL-CLMUPF-20221129144527

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609982
Report Date: 11/17/2022
Date Signed: 11/18/2022 12:08:49 PM

Substantiated

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
11/15/2022 and conducted by Evaluator Sandra Urena

COMPLAINT CONTROL NUMBER: 29-AS-20221115114033

FACILITY NAME:	PARADISE IN THE VALLEY LLC		FACILITY NUMBER:	197609982
ADMINISTRATOR:	COHEN, YEHUDA		FACILITY TYPE:	740
ADDRESS:	13530 SHERMAN WAY		TELEPHONE:	(818) 902-9501
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91405
CAPACITY:	46	CENSUS: 38	DATE:	11/17/2022
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Yehuda Cohen		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff are not wearing PPE

INVESTIGATION FINDINGS:

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On 11/17/2022, Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced visit to investigate the allegation named above. LPA Urena arrived at the facility at 1:30 p.m., met with Business Office Manager, Aubriana Thomas, and spoke via phone with the administrator Yudah Cohen (323-806-0786), and explained the reason for the visit.

LPA Urena conducted a brief interview with the administrator over the phone, and asked about the staff’s use of face coverings/masks, and if any outside agencies had observed staff not wearing masks. The administrator stated that an outside agency had visited the facility, and that the agency representative had brought to their attention the use of the face coverings/masks.

Continues on LIC 9099 C...

Substantiated

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: 11/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022

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-20221115114033

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: PARADISE IN THE VALLEY LLC	FACILITY NUMBER: 197609982
	VISIT DATE: 11/17/2022

NARRATIVE

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Regarding the allegation, ‘Staff are not wearing PPE’, it is the concern of the Reporting Party (RP) that the facility has not been safeguarding residents by not practicing proper infection control. Upon arrival the LPA was allowed into the facility by a staff member wearing a mask. The office staff were found to be wearing a mask as well. At 1:45pm. and the LPA conducted the tour of the facility, and noticed caregivers and other staff wearing a mask. Additionally, the LPA asked staff if an outside agency had visited the facility recently, and had brought to their attention wearing personal protective equipment (PPE)? The staff stated that 'yes' an outside agency had visited the facility.

Based on the LPA’s interview with the administrator, and staff, and based on the information provided by a credible witness, there is sufficient evidence to support the allegation that the 'Facility was not following COVID-19 health, and safety protocol’. Therefore, this allegation is deemed Substantiated at this time.

The following deficiencies were observed (See LIC 9099-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview was conducted with facility representative, a copy of the report, and Appeal Rights were issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20221115114033

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: PARADISE IN THE VALLEY LLC	FACILITY NUMBER: 197609982
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/17/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/28/2022 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1(a)(2) 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... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Submit staff training sign in sheet and supporting documentation on Infection Control Practices- PIN 21-38-ASC regarding masks wearing in the facility to LPA by 11/30/2022.
	8 9 10 11 12 13 14	Based on observation, and interviews conducted, the Licensee did not comply with the section cited above, staff did not wear mask/face covering, while providing care and supervision to residents in care, which poses a potential health and safety risk to residents 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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022

LIC9099 (FAS) - (06/04)

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