<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 195850356
Report Date: 10/02/2024
Date Signed: 10/02/2024 12:16:42 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
09/25/2024 and conducted by Evaluator Trevor Byrne
COMPLAINT CONTROL NUMBER: 29-AS-20240925162510
FACILITY NAME:PARADISE SENIOR HOMEFACILITY NUMBER:
195850356
ADMINISTRATOR:DAVTYAN, KNARIKFACILITY TYPE:
740
ADDRESS:7639 ALCOVE AVETELEPHONE:
(818) 601-0013
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY:6CENSUS: 0DATE:
10/02/2024
UNANNOUNCEDTIME BEGAN:
08:59 AM
MET WITH:Knarik DavtyanTIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff accepted a resident that required a higher level of care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced complaint investigation visit at the facility at 8:59 a.m. LPA met with the facility administrator Knarik “Nar” Davtyan (S1) the reason for the visit was explained and entrance interview was conducted.

During today’s visit the LPA conducted a physical plant tour and interviewed the facility administrator between 09:04 a.m. and 09:50 a.m. There are currently no residents residing at the facility. The allegation of “Staff accepted a resident that required a higher level of care” alleges that S1 accepted R1 into their care despite R1 requiring a higher level of care than the facility was able to provide. S1 stated during the interview that R1 was transferred to their facility through a placement agency from a skilled nursing facility (SNF) seventy-five (75) miles away. S1 stated that they had not conducted a pre-admission appraisal of R1 prior to accepting R1 into their care and took the word of others and the placement agency that this resident would be a good fit for their facility.
Report Continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024
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 5
Control Number 29-AS-20240925162510
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: PARADISE SENIOR HOME
FACILITY NUMBER: 195850356
VISIT DATE: 10/02/2024
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
Continued from 9099.

S1 described R1 having a violent outburst and stated that the resident eloped after only one (1) to two (2) hours. S1 also could not recall R1’s diagnosis. Based on the information obtained during the interview there is sufficient evidence to support the allegation of Staff accepted a resident that required a higher level of care. Therefore, the allegation is deemed Substantiated at this time.

The following deficiencies were cited (refer to LIC 9099Ds). A copy of the report was printed, appeal rights were provided, and exit interview was conducted.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20240925162510
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PARADISE SENIOR HOME
FACILITY NUMBER: 195850356
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/16/2024
Section Cited
CCR
87457(c)(1)
1
2
3
4
5
6
7
87457 Pre-Admission Appraisal General
(c) Prior to admission a determination of the... resident's suitability for admission shall be completed...
(1) The appraisal shall include... an evaluation of the... resident's...mental condition and...social factors...
1
2
3
4
5
6
7
Licensee will submit a statement of understanding confirming that they have reviewed and understand the entirety of CCR 87457 to CCL no later than POC due date.
8
9
10
11
12
13
14
This requirement is not met as evidenced by:
Based on interview the licensee failed to comply with the section cited above as no preadmission appraisal was conducted for R1 which poses a potential halth, safety, and personal rights risk to clients in care
8
9
10
11
12
13
14
Type B
10/16/2024
Section Cited
CCR
87464(d)
1
2
3
4
5
6
7
87464 Basic Services
d) ...if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs... providing the other basic services specified below, either directly or through outside resources.
1
2
3
4
5
6
7
Licensee will submit a statement of understanding confirming that they have reviewed and understand the entirety of CCR 87464 to CCL no later than POC due date.
8
9
10
11
12
13
14
This requirement is not met as evidenced by:
Based on interview the licensee stated R1 is not fit for a board and care facility and requires a higher level of care which poses a potential halth, safety, and personal rights risk to clients in care
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
09/25/2024 and conducted by Evaluator Trevor Byrne
COMPLAINT CONTROL NUMBER: 29-AS-20240925162510

FACILITY NAME:PARADISE SENIOR HOMEFACILITY NUMBER:
195850356
ADMINISTRATOR:DAVTYAN, KNARIKFACILITY TYPE:
740
ADDRESS:7639 ALCOVE AVETELEPHONE:
(818) 601-0013
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY:6CENSUS: 0DATE:
10/02/2024
UNANNOUNCEDTIME BEGAN:
08:59 AM
MET WITH:Knarik DavtyanTIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff illegally evicted resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced complaint investigation visit at the facility at 8:59 a.m. LPA met with the facility administrator Knarik “Nar” Davtyan (S1) the reason for the visit was explained and entrance interview was conducted.


During today’s visit the LPA conducted a physical plant tour and interviewed the facility administrator between 09:04 a.m. and 09:50 a.m. There are currently no residents residing at the facility. The allegation of “Staff illegally evicted resident” alleges that S1 illegally evicted Resident 1 (R1) within a day of R1’s arrival and R1 dropped off at a hospital by a good Samaritan after observing R1 partially clothed in the streets. During the interview with S1 they stated that R1 was referred to the facility through a placement agency. R1 arrived at the facility after being transferred from a Skilled Nursing Facility (SNF) seventy-five (75) miles away. S1 stated that they did not perform a pre-admission appraisal prior to accepting R1.
Continued on 9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20240925162510
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: PARADISE SENIOR HOME
FACILITY NUMBER: 195850356
VISIT DATE: 10/02/2024
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
Continued from 9099.

S1 stated that once R1 arrived at the facility via a private transport R1 refused to hand over their paperwork to S1. R1 then grew combative towards S1 and began verbally assaulting them and throwing furniture. S1 stated that R1 eloped from the facility after only one (1) to two (2) hours. S1 stated they were fearful for their safety and did not stop R1 from leaving the facility on their own volition. S1 confirmed that at no point had they initiated eviction procedures for R1 or asked R1 to leave the facility. S1 stated that they did not report the incident to Community Care Licensing Division or the authorities because they did not have any information on R1, which will be addressed under separate cover. Based on the information obtained, although the allegation may have happened or is valid, there is not sufficient evidence to support the allegation of staff illegally evicted resident occurred. Therefore, the allegation is deemed Unsubstantiated at this time.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5