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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200312
Report Date: 02/08/2023
Date Signed: 02/08/2023 01:04:12 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, 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
06/02/2022 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20220602104410
FACILITY NAME:PARADISE VILLA SENIOR CARE, LLCFACILITY NUMBER:
079200312
ADMINISTRATOR:KONAH DOLOFACILITY TYPE:
740
ADDRESS:836 SAN SIMEON DRIVETELEPHONE:
(925) 483-2595
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY:6CENSUS: 3DATE:
02/08/2023
UNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Dennis Sayson, AdministratorTIME COMPLETED:
01:13 PM
ALLEGATION(S):
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Resident is not administered medications when requested
Staff are not properly trained
INVESTIGATION FINDINGS:
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On 02/08/2023 at 11:25 AM, Licensing Program Analysts (LPA), J. Clancy-Czuleger arrived unannounced to deliver complaint findings for the above allegations. LPA met with Dennis Sayson, Administrator and explained the reason for the visit.

During the course of investigation, LPA obtained information, collected documents and interviewed staff and residents. On the allegation facility Resident is not administered medications when requested, based on record review the facility did not log any distrabution of the PRN medication for R1.

On the allegation staff are not properly trained, based on record review the facility did not have records of the staff having Hoyer Lift training in their training logs.

Continued on LIC9099C...

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023
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 4
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
06/02/2022 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20220602104410

FACILITY NAME:PARADISE VILLA SENIOR CARE, LLCFACILITY NUMBER:
079200312
ADMINISTRATOR:KONAH DOLOFACILITY TYPE:
740
ADDRESS:836 SAN SIMEON DRIVETELEPHONE:
(925) 483-2595
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY:6CENSUS: 3DATE:
02/08/2023
UNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Dennis Sayson, AdministratorTIME COMPLETED:
01:13 PM
ALLEGATION(S):
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9
Illegal eviction
Communication barriers between resident and staff
Staff not assisting resident's when needed
INVESTIGATION FINDINGS:
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On 02/08/2023 at 11:25 AM, Licensing Program Analysts (LPA), J. Clancy-Czuleger arrived unannounced to deliver complaint findings for the above allegations. LPA met with Dennis Sayson, Administrator and explained the reason for the visit.

During the course of investigation, LPA obtained information, collected documents and interviewed staff and residents.

Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 15-AS-20220602104410
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: 02/08/2023
NARRATIVE
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Continued from 9099....

Based on LPA’s interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22 has been cited.

Exit interview conducted. A copy appeal rights, and this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20220602104410
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: 02/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/24/2023
Section Cited
CCR
87465(c)(3)
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A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.

This requirement is not met as evidenced by…
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The facility will have a staff training disscusing medication and maintaining resident's records. Proof of correction will be sent to CCLD by POC date.
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The facility did not log the date and time the PRN medication was given to R1
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Type B
02/24/2023
Section Cited
CCR
87411(d)
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All personnel shall be given on the job training .... This training ... shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance.

This requirement is not met as evidenced by…
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The facility will go thorugh all staff records and update trainings for all staff. The facility will create a schedule of training that will be conducted each month for the next year.

Proof of correction will be sent to CCLD by POC date.
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The facility did not have the staff records of training in using a Hoyer Lift.
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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.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4