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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608233
Report Date: 08/18/2022
Date Signed: 08/19/2022 10:16:46 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
08/16/2022 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20220816113956
FACILITY NAME:AMAZING PARADISE HOME CAREFACILITY NUMBER:
197608233
ADMINISTRATOR:YOLANDA BERNARDOFACILITY TYPE:
740
ADDRESS:312 WEST 229TH STREETTELEPHONE:
(310) 549-9888
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY:6CENSUS: 4DATE:
08/18/2022
UNANNOUNCEDTIME BEGAN:
09:03 AM
MET WITH:Yolanda BernardoTIME COMPLETED:
03:59 PM
ALLEGATION(S):
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Illegal eviction.
The facility abandoned resident at hospital.
INVESTIGATION FINDINGS:
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On 08/17/22 Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced complaint visit at this facility. LPA Dabuet was greeted by caregiver Christian Matsler. Matsler contacted licensee and administrator Yolanda Bernardo by telephone. LPA Dabuet met with the administrator and explained the purpose of today's visit.

The investigation included the following; A review of the Client roster, Staff roster, Face sheet, Admission Agreement, Physician's Report, Preplacement Appraisal, ID/Emergency, Medication Administration Records, and other pertinent documents associated with Resident #1 (R1). Interviews were conducted with staff #1-#2 (S1-S2) and witnesses #1 - #2 (W1-W2). A tour of the facility was conducted.

Evaluation Report continues on LIC 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2022
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 4
Control Number 11-AS-20220816113956
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: AMAZING PARADISE HOME CARE
FACILITY NUMBER: 197608233
VISIT DATE: 08/18/2022
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Illegal eviction.
The facility abandoned resident at the hospital.
The details on this complaint state resident #1 (R1) was illegally evicted and abandoned at the hospital by the facility. The complainant reported (R1) was dropped off at the hospital on 08/11/22 and was inappropriately returned to a family member who was asked to meet in front of the hospital. The complainant states the family member was contacted by administrator staff #1 (S1) to meet (R1) at the hospital. It was reported that (S1) is no longer able to care for (R1) as he ran out of medications. The Department reached out to the complainant and was unable to obtain additional information. An interview with family member witness #1 (W1) states that (R1) was admitted to this facility for over 30 days. (R1) admitted himself with the assistance of Life Tree Foundation who contacted the licensee and made arrangements. (W1) claims the licensee/administrator at this facility is accommodating, cooperative and helpful. (W1) reports that (R1) does not have a legal guardian and that Life Tree Foundation was involved with his financial matters. (W1) claims she is uncertain if (R1) was illegally evicted or abandoned as (S1) has been in communication with (W1). (W1) reports (R1) is still in at Harbor UCLA Medical Center under observation. An interview with staff #1 (S1) claims (R1) was admitted to this facility on 07/13/22. (R1) went through the proper admissions procedures with a preplacement appraisal, physician's report, and admission agreement. (R1) was a resident from 07/13/22 through 08/11/22. (S1) states she accepted (R1) on a volunteer basis. (R1) came from Life Tree Foundation a non-profit organization that assisted with the funding of homeless individuals. (S1) claims she accepted (R1) on a charitable lower rate than the normal basic service rate. According to (S1) she did not charge for optional services. The funding agreement for (R1) is paid through contribution from the Life Tree Foundation. However, (R1) was out of medications and with no public guardian; (S1) was contacted the case manager witness #2 (W2) of Life Tree Foundation. (W2) arranged for a transportation service to admit (R1) in the hospital for observation to obtain medications. (S1) coordinated with (W1-W2) and made arrangements with (W1) to meet with (R1) at the hospital through transportation provided by Life Tree Foundation. (S1) claims she did not know what transpired was considered an illegal eviction and did not constitute what happened was considered an abandonment of (R1). (S1) reports she did not go through the proper Eviction Procedures as required by Title 22, Division 6, Chapter 8.

Evaluation Report continues LIC 9099-C
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20220816113956
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: AMAZING PARADISE HOME CARE
FACILITY NUMBER: 197608233
VISIT DATE: 08/18/2022
NARRATIVE
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(S1) asserts she thought she was only doing what was best under the circumstances and followed directives from (W2) at Life Tree Foundation. (S1) claims she had no contact with the hospital or with (R1) only with the family member for (R1). An interview with case manager witness #2 (W2) confirms that (R1) came to the program homeless and did not have family who wanted to get involved financially with (R1's) well-being. Life Tree Foundation assisted with placing the (R1) in an assisted living home through donations. (W2) admitted that he gave directives on how to handle (R1's) admission at the hospital where (R1) has an active LA Care Health Plan and to allow the family members to be involved for the welfare of (R1).

Based on the Department's observation and interviews, records reviews, and analysis, the preponderance of evidence standard has been met, therefore the allegations of "Illegal Eviction" and "The facility abandoned resident at the hospital" is Substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC 9099-D.

An exit interview was conducted with Yolanda Bernardo. The Rights were discussed and a copy of Appeals Procedures for Licensees was provided, as well as a copy of this report to the Administrator.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 11-AS-20220816113956
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: AMAZING PARADISE HOME CARE
FACILITY NUMBER: 197608233
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/26/2022
Section Cited
CCR
87224(a)(1-5)
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87224 Eviction Procedures - (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5)...

This requirement was not met as evidence by:
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Licensee will review Title 22 Section 87224 and will outline a plan on how to adhere to eviction procedure and re-evaluate residents to reflect Title 22. Licensee will send copy by POC due date to LPA Dabuet by 08/26/22.
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Based observations, interviews and analysis, Licensee did not take the appropriate eviction steps and displaced (R1) at the hospital effective 08/11/22. This is a potential health and safety risk to clients in care.
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Type B
08/26/2022
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities - (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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Licensee will review Title 22 section 87468.1 and will adhere to the regulations. Licensee will send plan by POC due date to LPA Dabuet by 08/26/22.
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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.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4