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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850356
Report Date: 10/02/2024
Date Signed: 10/02/2024 12:20:07 PM

Document Has Been Signed on 10/02/2024 12:20 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:PARADISE SENIOR HOMEFACILITY NUMBER:
195850356
ADMINISTRATOR/
DIRECTOR:		DAVTYAN, KNARIKFACILITY TYPE:
740
ADDRESS:7639 ALCOVE AVETELEPHONE:
(818) 601-0013
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY: 6CENSUS: 0DATE:
10/02/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:59 AM
MET WITH:Knarik DavtyanTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced Case Management – Deficiencies inspection to issue citations observed during a complaint investigation. The LPA met with Administrator Knarik “Nar” Davtyan.

LPA conducted an interview with facility administrator Knarik “Nar” Davtyan (S1) between 09:04 a.m. and 09:50 a.m. During the interview S1 stated that Resident 1 (R1) had eloped from the facility on 09/05/2024 after a violent outburst. S1 stated that they were fearful for their safety at the time. S1 stated that they had not reported to Community Care Licensing Division (CCLD) that they had accepted a resident into their care. S1 also stated that after the elopement incident of R1 they failed to alert local law enforcement or report to CCLD. LPA confirmed that no incident report was submitted for this incident. When asked why no reports were made S1 stated, “I was fearful for my safety, I had no information on the resident what would I have to report?” LPA informed S1 on the reporting requirements for a resident eloping from a facility. S1 acknowledged that they should’ve called to report to CCLD and the police.

Pursuant to Title 22 of the CA Code of Regulations and Health and Safety Code, the following deficiencies were cited (refer to LIC 809-Ds): Exit interview conducted and copy of the report was issued and appeal rights provided.
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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/02/2024 12:20 PM - It Cannot Be Edited


Created By: Trevor Byrne On 10/02/2024 at 11:40 AM
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. #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
87211(a)(1)(D)

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87211(a)(1)(D) Reporting Requirements (a) Each licensee shall...including...the following: 1) A...report...within seven days...include...nature of event. (D) Any incident which threatens the welfare, safety or health of any residen...or unexplained absence of any resident
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Licensee will submit a statement of understanding confirming that they have reviewed the entirety of CCR 87211. Aditionally, Licensee will submit a statement confirming that they understand the importance of timely reporting to CCL no later than POC due date.
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This requirement is not met as evidenced by:
Based on interview the licensee failed to comply with the section cited above as no special incident report was submitted for the elopment of R1 which poses a potential halth, safety, and personal rights risk to clients in care
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Type B
10/16/2024
Section Cited
HSC1569.317

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§1569.317 Absentee notification plan for missing residents. Every residential care facility for the elderly...shall...develop...an absentee notification plan...shall include...a requirement that an administrator... shall notify local law enforcement when a resident is missing from the facility.
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Licensee will submit a statement of understanding confirming that they have reviewed the entirety of HSC 1569.317. Aditionally, Licensee will submit a statement confirming that they understand the importance of timely reporting tolaw enforcement no later than POC due date.
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This requirement is not met as evidenced by:
Based on interview the licensee failed to comply with the section cited above as no report was made to law enforcement for the elopment of R1 which poses a potential halth, safety, and personal rights risk to clients in care
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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: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


LIC809 (FAS) - (06/04)
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