079200312-3-16-2021-15-AS-KHOS-BZ7QAJ-20210317120002

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200312
Report Date: 03/11/2021
Date Signed: 03/16/2021 02:09:42 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:	03:42 PM
MET WITH:	Sehida Krasnic		TIME COMPLETED:	04:48 PM

ALLEGATION(S):

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-Protruding nail on top of doorframe on front door.
-Open crack in the attic door in the hallway.

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.

Allegation: Protruding nail on top of doorframe on front door.The nail was observed to be protruding from the door frame on the front door by ombudsman. Ombudsman had it removed during her visit. During a video phone interview with S1, LPA asked what the nail was used for; S1 stated it was previously used to prevent a resident from leaving. SUBSTANTIATED.

Continuation on LIC 9099C

Substantiated

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: Open crack in the attic door in the hallway. During a video tour of the facility, LPA observed the large crack in attic cover in hallway, located just outside of residents' bedroom door (screenshot found in interview LIC812). The split attic cover poses a risk to residents health and safety. SUBSTANTIATED.

The Department has investigated the above allegations and per interviews conducted and records reviewed, the preponderance of evidence standard has been met and both are substantiated. Deficiencies are cited from Title 22 California Code of Regulations (see 9099D). Failure to submit proof of correction by plan of correction due date and any repeat violations within 12-month period may result in civil penalties.

Exit interview conducted with Administrator, Sehida Krasnic. Appeal Rights and copy of this report provided via PDF email.

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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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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/11/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/17/2021 Section Cited CCR 87468.1(a)(6)	1 2 3 4 5 6 7	(a) Residents in all RCFEs shall have the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night.	1 2 3 4 5 6 7	Corrected on 10/06/2021, Ombudsman asked staff to remove nail, which they did.
	8 9 10 11 12 13 14	Ombudsman found nail protruding from top of main doorway which was admitted to previously keep a resident from opening door.	8 9 10 11 12 13 14
Type B 03/17/2021 Section Cited HSC 87303(a)	1 2 3 4 5 6 7	(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include... procedures for the safety and well-being of residents, employees and visitors.	1 2 3 4 5 6 7	Corrected on 11/1/2021, attic door cover was replaced.
	8 9 10 11 12 13 14	Crack was observed down the middle of attic door in ceiling between two residents two rooms.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

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 appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2021

LIC9099 (FAS) - (06/04)

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