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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610199
Report Date: 01/07/2025
Date Signed: 01/27/2025 02:40:56 PM

Document Has Been Signed on 01/27/2025 02:40 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:A PARADISE VILLAFACILITY NUMBER:
197610199
ADMINISTRATOR/
DIRECTOR:		HAKOBYAN, ANNAFACILITY TYPE:
740
ADDRESS:9925 COLLETT AVE.TELEPHONE:
(818) 919-5595
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY: 6CENSUS: 5DATE:
01/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:HAKOBYAN, ANNA- AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
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This is an amendment report that civil penalty is updated to $1000 only.
Licensing Program Analyst (LPAs) Leslie Ngo-Castaneda and Nadia Shahbazian conducted an annual required visit and inspection of the facility. At 11 am staff Senya Issachenko and Darya Issachenko met with LPA, explained the reason for the visit. Staff was not associated with Guardian, a civil penalty will be issued. At 1:30PM licensee Anna Hakobyan arrived and was advised the reason of the visit.

At 1:07 PM, with the assistance of staff, LPAs took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are operational that are located each bedroom, the hallway and kitchen. There are carbon monoxide detectors that functions properly. The fire extinguisher is in the kitchen the charge date is 6.22.2024 During the visit the facility is at 75 degrees Fahrenheit. The facility is fire cleared for six (06) non-ambulatory residents. Hospice waiver for six (6).

Kitchen: The kitchen appliances and fixtures were functional. The kitchen has a working gas stove, faucet, freezer, refrigerator, and microwave. LPA found enough at least two (2) days perishable and seven (7) days non-perishable food at the facility that is properly stored. Frozen foods are wrap, dated, and stored properly as well. Knives were stored in an locked cabinet in the kitchen. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers. Cleaning supplies, pesticides or toxic cleaning supplies were stored and locked in the kitchen below the sink.

Bedrooms: There were three (3) bedrooms designated for residents' use. Bedroom #1, bedroom #2, and bedroom #3 are shared. Bedrooms that are used by the residents were properly furnished with appropriate dresser, beddings, and linens with sufficient lighting.

Continue to LIC 809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE: DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: A PARADISE VILLA
FACILITY NUMBER: 197610199
VISIT DATE: 01/07/2025
NARRATIVE
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Bathrooms: There are two (2) bathroom designated for residents' use. The bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 118.8 degrees Fahrenheit in the bathrooms. Bathroom #1 is located beside bedroom #1. Bathroom #2 is inside bedroom #3. There was enough clean linen available in the cabinets in the laundry room.

Common Areas: LPA toured all common areas of the facility. These included the living room and dining area for residents. The common areas were properly furnished. Residents dining table fits enough for six (6). LPA observed common areas to be very clean and tidy. LPA observed the floors to be in very good condition. No obstructions and or tripping hazards throughout the facility. Furniture in common area was observed to be in good repair. There are no issues with Fire Clearance.

Infection control: Facility mitigation plan to make sure licensee was following current infection control recommendations. LPA obtain a copy and reviewed the infection control plan during this visit.

Surrounding Grounds: Entry and exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The facility does have a swimming pool it is fence up and lock. The garage is detached and is converted into an office.

Laundry service: There is enough linen available to change weekly or more if need. Cleaning supplies are being stored in a locked cabinet in the laundry area in the kitchen.

Staff Files: LPA also conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms. Records were checked for expired or missing certificates and clearances: LPA conducted a file review of staff for criminal record clearances and current First Aid. The administrator file was reviewed for current first aid, fingerprint clearance, administrator certificate, and HIV/AIDS and TB training.

Continue to LIC 809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: A PARADISE VILLA
FACILITY NUMBER: 197610199
VISIT DATE: 01/07/2025
NARRATIVE
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Medications are in a centrally stored and locked place, including over-the-counter medicines; medications are properly labeled and checked for expiration dates. Each centrally stored prescription and PRN medication has been logged in the medications log with proper documentation from the clients’ doctor. Proper medication dispensing instruction are followed and checked for contamination. First-aid has all proper items and is current. R2 injection was found in the refrigerator which was unlock and inaccessible. Deficiency will be cited in LIC 809-D. LPA also observed a surplus of medication for R5 and it was advised that they refuse to take medication. No incident report was receive. Deficiency will be cited in LIC 809-D.

Resident records were reviewed for requirements and legibility: LPA reviewed client’s files for current appraisal. Planned activities are offered.

Deficiencies were found and listed in LIC 809-D, exit interview conducted, copy of report has been issued and discussed.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 01/07/2025 06:31 PM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 01/07/2025 at 02:59 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: A PARADISE VILLA
FACILITY NUMBER: 197610199

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(d)(3)
Criminal Record Clearance
(3) The licensee shall submit these fingerprints to the California Department of Justice, along with a second set of fingerprints for the purpose of searching the records of the Federal Bureau of Investigation, or comply with Section 87355(c), prior to the individual's employment, residence, or initial presence in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 2 staff fingerprint clearance was not done which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/14/2025
Plan of Correction
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Staff needs staff files upon onboarding: CPR, fingerprint clearance, training, and be associated w/ Guardian.
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 2 staff LIC 508 was not done which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/14/2025
Plan of Correction
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Staff needs staff files upon onboarding: CPR, fingerprint clearance, LIC 508, health screening, TB test, training, and be associated w/ Guardian.
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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE: 01/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/07/2025


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Document Has Been Signed on 01/07/2025 06:31 PM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 01/07/2025 at 03:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: A PARADISE VILLA
FACILITY NUMBER: 197610199

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.619(c)(3)
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 2 staff no CPR was not done which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/14/2025
Plan of Correction
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Staff needs staff files upon onboarding: CPR, fingerprint clearance, LIC 508, health screening, TB test, training, and be associated w/ Guardian.
Type A
Section Cited
CCR
87465(H)(1)(A)


This requirement is not met as evidenced by:
A) The preservation of medicines requires refrigeration, if the resident has no private refrigerator.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 1 R3 injection was accessible in the refrigerator which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/08/2025
Plan of Correction
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Licensee and staff needs to keep rx in the refrigetor locked.
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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE: 01/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/07/2025


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 01/07/2025 06:31 PM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 01/07/2025 at 03:20 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: A PARADISE VILLA
FACILITY NUMBER: 197610199

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87211(a)(1)
A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.

This requirement is not met as evidenced by:

Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 1 incident report was not submitted to RO for R5 refusal of rx, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/14/2025
Plan of Correction
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LIC 624 needs to be submitted to LPA when residents refuses medication or any incident.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE: 01/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/07/2025


LIC809 (FAS) - (06/04)
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