079200312-3-16-2021-15-AS-KHOS-BZ7QAK-20210317120002

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200312
Report Date: 03/11/2021
Date Signed: 03/16/2021 02:07:48 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/09/2020 and conducted by Evaluator Jacob Williams

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20201009160721

FACILITY NAME:	PARADISE VILLA SENIOR CARE, LLC		FACILITY NUMBER:	079200312
ADMINISTRATOR:	KONAH DOLO		FACILITY TYPE:	740
ADDRESS:	836 SAN SIMEON DRIVE		TELEPHONE:	(925) 262-9476
CITY:	CONCORD	STATE: CA	ZIP CODE:	94518
CAPACITY:	6	CENSUS:	DATE:	03/11/2021
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Sehida Krasnic		TIME COMPLETED:	04:48 PM

ALLEGATION(S):

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Residents had access to cleaning supplies.

INVESTIGATION FINDINGS:

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On Thursday, March 11, 2021, Licensing Program Analyst (LPA) J. Williams called facility to deliver the findings for the above allegations. LPA spoke with Administrator Sehida Krasnic. Due to the Executive Order of Shelter in Place set forth by the Governor, the LPA was not able to deliver the findings in person.

During the course of the investigation, the Department conducted interviews with Reporting Party (RP), staff and resident.

Continuation on LIC 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Jacob Williams	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2021

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 15-AS-20201009160721

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: PARADISE VILLA SENIOR CARE, LLC	FACILITY NUMBER: 079200312
	VISIT DATE: 03/11/2021

NARRATIVE

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Allegation: Residents had access to cleaning supplies. Ombudsman explained to LPA that during her visit, she observed cleaning supplies left out on the floor and shelves of the bathroom.The caregivers put them away when the ombudsman asked. Upon interview of S1, S2, and R1, all denied ever seeing or leaving any cleaning product unattended at facility. S2 stated all staff are trained and taught not to leave any cleaning product out unattended. There is no sufficient evidence that any cleaning supplies were left unattended.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Jacob Williams	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2021

LIC9099 (FAS) - (06/04)

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