197609982-3-16-2023-29-AS-JAPL-CSC2D8-20230530171756

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609982
Report Date: 03/16/2023
Date Signed: 03/16/2023 03:20:09 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 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
03/07/2023 and conducted by Evaluator Christine Yee

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20230307132101

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: 40	DATE:	03/16/2023
		UNANNOUNCED	TIME BEGAN:	08:55 AM
MET WITH:	Yehuda Cohen, Administrator		TIME COMPLETED:	03:35 PM

ALLEGATION(S):

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1. Staff did not prevent resident from assaulting another resident in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Yee conducted an inital complaint visit to investigate the above allegation and initially met with Evelyn Pena, Wellness Director. Yehuda Cohen, Administrator arrived at 10:07am to conduct the visit. The reason for today's visit was explained.

LPA Yee conducted face to face interviews with Evelyn Pena at 10:01am, Administrator at 10:26am, Resident #1 at 10:51am and conducted telephone interviews with Staff #1 at 12:29pm, Staff #2 at 2:31pm and Witness #1 at 11:26am. Facility files were reviewed and copies of files requested from 11:45am - 12:25pm, Resident #1's room and area directly in front of the room was toured at 1:30pm.

Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

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-20230307132101

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: PARADISE IN THE VALLEY LLC	FACILITY NUMBER: 197609982
	VISIT DATE: 03/16/2023

NARRATIVE

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Per information received from interviews conducted with the Administrator, Wellness Director, Staff #1 and Resident #1, on 2/28/23 around 7:00pm screaming was heard coming from the area where Resident #1's room is located. Resident #3 also came to get Staff #1 in the dining room and gestured to staff to hurry. Staff #1 followed Resident #3 around to the other side of the building and found Resident #2 standing over Resident #1.
Resident #2 was beating and dragging Resident #1 in the hallway directly outside their shared bedroom. Staff #1 intervened and told Resident #2 to let Resident #1 go. With the assistance of Staff #1, Resident #1 was able to get away. Resident #2 attempted to hit Staff #1 and succeeded in hitting staff on the collar bone. Resident #2 also attempted to choke Staff #1. Staff #1 was screaming for assistance and trying to calm the resident down. Staff #1 wanted to know why Resident #2 was acting that way. Staff #2 had also heard the screaming and ran towards the screaming just in time to see Staff #1 being hit by Resident #2. Resident #2 also attempted to hit Staff #2 and a caregiver hired from an agency. Resident #2 was very agitated. Staff #2 contacted family to assist Resident #2 calm down but the phone was disconnected by resident so 911 was called. When the paramedics arrived, Resident attempted to attack Staff #1 a third time but the paramedic's intervened. Resident #1 refused to be transported to the hospital to be checked on the day of the incident. Resident sustained injury to both elbows and to the top right side of face and to the back of the right ear. First aid was rendered by the paramedics. However, Resident #2 was transported to the hospital and is currently still under observation. Two days later, Resident #1 agreed to be transported to the hospital for a CT scan. No internal injuries were noted.

Per interviews conducted with staff and Resident #1, all indicated that Resident #2 is very calm and is not aggressive. Everyone indicated that this was not Resident #2's normal behavior.

Based on the information obtained during the investigation, the finding for the above allegation is UNSUBSTANTIATED.

Exit interview was conducted with the Administrator and a copy of report provided.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023

LIC9099 (FAS) - (06/04)

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