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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609980
Report Date: 04/06/2023
Date Signed: 04/06/2023 06:41:19 PM

Substantiated


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
03/16/2023 and conducted by Evaluator Sandra Urena
COMPLAINT CONTROL NUMBER: 29-AS-20230316082259
FACILITY NAME:AMY'S PARADISE HOME OF ANGELS INC.FACILITY NUMBER:
197609980
ADMINISTRATOR:EMMA AVETISYANFACILITY TYPE:
740
ADDRESS:11950 ROSCOE BLVDTELEPHONE:
(310) 913-6161
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY:6CENSUS: 5DATE:
04/06/2023
UNANNOUNCEDTIME BEGAN:
06:10 PM
MET WITH: Emma AvetisyanTIME COMPLETED:
07:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff abused residents in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst(LPA) Sandra Urena conducted a subsequent unannounced visit to deliver the findings for the allegation above. The LPA arrived at 6:10 p.m., and was greeted by staff. The staff contacted the Administrator Emma Avetisyan via phone, and the LPA explained the reason for the visit. Administrator was not able to come to the facility.

On 03/22/2023, Licensing Program Analyst(LPA) Sandra Urena conducted an initial unannounced visit to investigate the allegation above. The LPA arrived at 1:51 p.m., and was greeted by staff. The staff contacted the Administrator Emma Avetisyan via phone, and explained the reason for the visit. Administrator was unable to come to the facility. LPA Urena interviewed the Administrator and staff from to 2:00 p.m. to 2:30 p.m. LPA Urena attempted to interview the residents.
Continues on LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023
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 3
Control Number 29-AS-20230316082259
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: 04/06/2023
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
On the allegation that ‘Staff abused residents in care’; it is the complainant’s concern that the residents are being abused possibly physically, due to complainant hearing screams from a resident, possibly being hit, while screaming and banging was also heard. To investigate the complaint, on 03/22/2023, the LPA conducted collateral interviews about the incident witnessed by the public. The interviews revealed that staff #1(S1) was observed forcefully pulling R1, and trying to pull R1 into the facility’s front yard. Both, S1 and R1 were observed outside the perimeter fence of the facility, where R1 was holding on to one of the pillars of the fence, and S1 was observed pulling R1 aggressively. Additionally, it was observed that S1 pulled R1 into the front yard, and R1 fell to the ground, causing R1’s pants to fall half-way down. S1 was eventually able to pull R1 back inside the facility. The LPA interviewed the Administrator, and the interview revealed that the Administrator was informed by S1 about the incident of R1 attempts to elope the facility. Per the administrator, R1 eloped the facility through the side gate, and when the S1 noticed that R1 had exited the front gate, S1 attempted to bring back R1 into the facility. The Administrator stated that R1 fell while attempting to elope.

Based on the information obtained through interviews, there is sufficient evidence to support the allegation that staff violated R1’s personal rights by forcefully restraining R1 to prevent R1 from eloping from the facility, causing the fall and potential bruising on R1. Therefore, the allegation is deemed Substantiated at this time.

The following deficiencies were observed (See LIC 9099-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Citations were issued. Exit interview was conducted with Administrator on the phone, and the facility representative signed the report. A copy of the report and Appeal Rights were issued.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 29-AS-20230316082259
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/14/2023
Section Cited
CCR
87705(a)(k)(4)(5)(6)
1
2
3
4
5
6
7
(4)Without violating ... Personal Rights, facility staff shall attempt to redirect a resident who attempts to leave the facility.(5)Residents who continue to indicate a desire to leave the facility following redirection shall be permitted to do so with staff supervision.
Personal Rights, facility ... the continued safety of residents if they wander... facility. This requirement was not met as evidence by:
1
2
3
4
5
6
7
Administrator agrees to review the regulations with staff as they pertain to caring to persons with dementia. Submit staff training sig in sheet, training agenda and materials/handouts used for training by 04/14/2023.
8
9
10
11
12
13
14
Based on interviews, the licensee did not comply, R1 was able forcefully restrained while trying to leave the facility, which poses a potential safety risk to residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3