197603340-12-11-2024-11-AS-RORN-DE8UUF-20250225145328

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603340
Report Date: 12/10/2024
Date Signed: 12/11/2024 02:54:20 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/02/2024 and conducted by Evaluator Pamela Bunker

COMPLAINT CONTROL NUMBER: 11-AS-20241202105527

FACILITY NAME:	EXCLUSIVE RAYA'S PARADISE, INC.		FACILITY NUMBER:	197603340
ADMINISTRATOR:	ISRAEL & MOTI GAMBURD		FACILITY TYPE:	740
ADDRESS:	341 N. LA JOLLA AVE.		TELEPHONE:	(323) 851-2517
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90048
CAPACITY:	6	CENSUS: 5	DATE:	12/10/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Arman Ahangarzadeh		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff did not ensure that resident is provided an adequate amount of food while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced complaint visit on Tuesday, December 10, 2024. Upon arrival at the facility. LPA Bunker called the facility via telephone and conducted a risk assessment. Based on the assessment, the facility is cleared of COVID-19 infection. LPA Bunker met with Licensed Vocational Nurse Arman Ahangarzadeh. LPA Bunker explained the purpose of today's visit.

The investigation consisted of the following: The department interviewed staff members 1-3 (S1-S3), residents 1-3 (R1-R3), witnesses 1-2 (W1-W2), and attempts were made to interview residents 4-6 (R4-R6). The department and S1-S3 toured the facility and observed the facility's food supply. The observation confirmed an ample supply of perishable and non-perishable foods. S1-S3, R1-R3, and W1-W2 stated that residents are served three (3) meals per day plus snacks and are provided with an adequate amount of food. S1-S3 and W1-W2 stated that modified diets prescribed by a resident's physician as a medical necessity are accommodated, and the facility follows all doctor's orders.
See continued LIC9099-C page 2

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024

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 11-AS-20241202105527

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: EXCLUSIVE RAYA'S PARADISE, INC.	FACILITY NUMBER: 197603340
	VISIT DATE: 12/10/2024

NARRATIVE

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Continued LIC9099-C page 2

S1-S3, R1-R3, and W1-W2 also stated that residents receive plenty of food to eat, and meals are served seven days a week, Sunday through Saturday, in accordance with the physician's directions. The total quality and quantity of food are sufficient to meet the resident's needs.

The department requested copies of the following documents: Personnel Report, Resident Roster, Special Incident Reports, Food Menu, Alternative Menu, Admission Agreement, Identification and Emergency Information, Physician's Report, Medical Assessment, Medication Administration Records (MARs), Medication Logs, Consent Forms, Replacement Appraisal Information, Appraisal and Needs Service Plan, Resident Progress Notes, Special Incident Reports, Guardian Angel Hospice Records, Cedar-Sinai Medical Records, In-Service Training, and any Ongoing Training.

Allegation: Staff did not ensure that the resident was provided an adequate amount of food while in care.
Staff members 1-3 (S1-S3), residents 1-3 (R1-R3), and witnesses 1-2 (W1-W2) were interviewed and stated that residents are adequately fed. S1-S3, W1-W2, and R1-R3 stated that residents receive three well-balanced meals per day—breakfast, lunch, and dinner—plus snacks. S1-S3 emphasized that the facility ensures residents are served a sufficient quantity of food.

R1-R3 reported that the portions provided are more than enough, with additional servings available if requested. They also mentioned that they have no concerns about the quantity of food being served and had no complaints about the quality or variety of meals.

S1-S3, W1-W2, and R1-R3 stated that residents have access to a variety of food options, and alternative meals are available if a resident does not want what is on the menu. R1-R3 noted that the food menu changes weekly, offering new options and that residents are not served the same meals repeatedly.

LPA reviewed the December 2024 food menus, which showed a diverse selection of meal options. S1-S3 stated that the menu is regularly updated based on feedback from residents and input from their physicians to meet dietary needs and preferences.
See continued LIC9099-C page 3

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20241202105527

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: EXCLUSIVE RAYA'S PARADISE, INC.	FACILITY NUMBER: 197603340
	VISIT DATE: 12/10/2024

NARRATIVE

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Continued LIC9099-C page 3

The investigation consisted of the following:
S1-S3 and W1-W2 stated that the resident’s physicians provided specific instructions regarding the amount and type of food the facility should provide to the resident, and they are strictly following the physician’s directions. S1-S3 and W1-W2 confirmed that the resident is on a special modified diet requiring liquid, pureed, soft, and moist foods.

S1-S3 reported that the resident’s family member visits the facility daily, feeds the resident the prescribed foods, and provides copies of the doctor’s orders. S1-S3 and W1-W2 stated that the resident has not been crying for food. They explained that the resident has dementia, is on hospice, and has not exhibited signs of crying for more food for approximately two to three weeks.

S1-S3 and W1-W2 also stated that the resident has a one-on-one caregiver who provides care 24 hours a day, seven days a week. According to S1-S3 and W1-W2, the staff, the resident’s family members, and the one-on-one caregiver all contribute to feeding the resident.

S1-S3 and W1-W2 stated that the staff at the facility are not intimidated by the resident’s relative or power of attorney (POA). S1-S3 and W1-W2 emphasized that they are strictly adhering to the physician’s orders according to Title 22 Regulations. Staff provided LPA with documentation outlining the resident’s modified diet recommendations as prescribed by the resident's physician.

Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed unsubstantiated.

There were no deficiencies cited.

An exit interview was conducted.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024

LIC9099 (FAS) - (06/04)

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