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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609980
Report Date: 10/26/2021
Date Signed: 10/26/2021 07:00:13 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
10/22/2021 and conducted by Evaluator Sandra Urena
COMPLAINT CONTROL NUMBER: 29-AS-20211022113023
FACILITY NAME:AMY'S PARADISE HOME OF ANGELS INC.FACILITY NUMBER:
197609980
ADMINISTRATOR:MADDEN, TAMMEFACILITY TYPE:
740
ADDRESS:11950 ROSCOE BLVDTELEPHONE:
(310) 913-6161
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY:6CENSUS: 4DATE:
10/26/2021
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Narine SargsyanTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff gave medication to residents without a physician's prescription order.
INVESTIGATION FINDINGS:
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On 10/26/2021, Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced initial 10-day complaint investigation visit regarding the above allegations. LPA Urena was greeted by the Caregiver at 3:30 pm. The Administrator, Emma Avestisyan was unavailable at the time; the caregiver contacted the administrator on the phone. The LPA spoke with the Administrator over the phone and informed them of the reason for the visit.

It is alleged that staff give sleeping medication to residents without a prescription. At 3:40pm, the LPA asked S1 for the residents’ files and medication logs for the four residents at the facility. The LPA reviewed the residents’ files, medication logs, and found that two out of the four residents have a doctor’s prescription for sleeping pills. The LPA audited medications during today’s visit. The LPA observed that R1 had a prescription for 5MG of Donepezil, and R2 had a prescription for 10MG of Donepezil.

Continues on LIC 9099C ...

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021
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 2
Control Number 29-AS-20211022113023
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: AMY'S PARADISE HOME OF ANGELS INC.
FACILITY NUMBER: 197609980
VISIT DATE: 10/26/2021
NARRATIVE
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The LPA asked the S1 to conduct a count of the pills in each of the bottles for R1, and R2. According to the prescription date on the bottle, number of pills prescribed, and pills remaining in the bottles, the medication is being administered as prescribed by physicians.

At 4:05 pm, LPA Urena and S1 conducted a tour of the facility, inside and outside to ensure there are no health and safety hazards, and the facility is in compliance with Title 22 Regulations. Kitchen appliances were in operable condition, knives were locked and out of reach of residents. Bathrooms had paper towels and hand washing signs. Shower had a nonskid pad. Bedrooms had adequate furniture, bedding linens, light, and personal space for each resident. During the tour of the facility, the LPA observed residents walking about the facility, from the bedroom to the common area, and to the bathroom.

At 4:15pm, LPA Urena interviewed administrator over the phone. At 4:20pm the LPA interviewed staff and residents. Residents stated that they watch TV during the day. S1 stated that the sleeping medication is administered after dinner. Dinner is between 7:00pm to 7:30pm and medication is administered to the two residents at around 8:00pm.

Based on the information obtained, there is insufficient evidence to support the claim that staff gave
medication to residents without a physician's prescription order. This allegation is deemed Unsubstantiated at this time.

Exit interview conducted. Report was read to Administrator over the phone. Administrator Emma Avetisyan allowed S1 to sign the report. The report was issued.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021
LIC9099 (FAS) - (06/04)
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