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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 330910554
Report Date: 09/29/2021
Date Signed: 09/29/2021 10:40:43 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/11/2019 and conducted by Evaluator David Cuevas
COMPLAINT CONTROL NUMBER: 18-AS-20191011155501
FACILITY NAME:PARADISE GUEST RANCHFACILITY NUMBER:
330910554
ADMINISTRATOR:VASQUEZ, CONNIEFACILITY TYPE:
740
ADDRESS:19150 KRIS ROADTELEPHONE:
(760) 329-8905
CITY:SKY VALLEYSTATE: CAZIP CODE:
92241
CAPACITY:6CENSUS: 4DATE:
09/29/2021
UNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Licensee, Connie VazquesTIME COMPLETED:
10:50 AM
ALLEGATION(S):
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Resident sustained multiple pressure injuries while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) David Cuevas conducted an unannounced visit to the facility above to deliver findings for complaint control #18-AS-20191011155501. LPA identified self and informed Licensee, Connie Vazques of the purpose of visit.

During the investigation process, LPA conducted facility file review, interviewed: staff, residents, and witnesses, and collected pertinent documents.

Regarding allegation # 1: Resident sustained multiple pressure injuries while in care.

Based on review of collected documents showed resident #1 (R1), having existing pressure injuries prior to being admitted to this facility. R1 was admitted to the facility on the night of 9/23/19, after hospital discharge. Examination of hospital discharge documentation dated 9/23/19 shows discharge to have occurred at approximately 1:30 PM, prior to being admitted to this facility.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: David CuevasTELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021
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 7
Control Number 18-AS-20191011155501
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: PARADISE GUEST RANCH
FACILITY NUMBER: 330910554
VISIT DATE: 09/29/2021
NARRATIVE
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Discharge summary identifies R1 to have been healing from existing wounds, discharge physician recommended wound care treatment to be continued upon discharge.Per interviews with staff members and hospice documentation reviewed, it appeared that R1 was receiving appropriate care while residing at the facility. Additionally, during R1’s facility file review identified that during R1’s residency at facility; home health services had been requested and monitored by a licensed professional.

As such this department deems the allegation of resident sustained multiple pressure injuries while in care to be UNSUBSTANTIATED; meaning that although the allegation may have happened or is valid, there is not enough preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

An exit interview was conducted with Licensee, Connie Vasquez, were a copy of this report was reviewed and provided.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: David CuevasTELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021
LIC9099 (FAS) - (06/04)
Page: 7 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/11/2019 and conducted by Evaluator David Cuevas
COMPLAINT CONTROL NUMBER: 18-AS-20191011155501

FACILITY NAME:PARADISE GUEST RANCHFACILITY NUMBER:
330910554
ADMINISTRATOR:VASQUEZ, CONNIEFACILITY TYPE:
740
ADDRESS:19150 KRIS ROADTELEPHONE:
(760) 329-8905
CITY:SKY VALLEYSTATE: CAZIP CODE:
92241
CAPACITY:6CENSUS: 4DATE:
09/29/2021
UNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Licensee, Connie Vasquez TIME COMPLETED:
10:50 AM
ALLEGATION(S):
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Staff did not allow emergency medical personnel access to resident's room
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) David Cuevas conducted an unannounced visit to the facility above to deliver findings for complaint control #18-AS-20191011155501. LPA identified self and informed Licensee, Connie Vazques of the purpose of visit.

During the investigation process, LPA conducted facility file review, interviewed: staff, residents, and witnesses, and collected pertinent documents.

Regarding allegation # 2: Staff did not allow emergency medical personnel access to resident's room.

On October 09, 2019 Family members to Resident # 1(R1) summoned the assistance of emergency personnel. Family members and emergency personnel arrived soon after. Facility Staff # 2 (S2) felt it was necessary to contact Staff # 3 (S3) for advice and permission on allowing emergency personnel to enter the facility. S3 would arrive later into the visit by family members and emergency personnel. Interviews revealed staff being reluctant in allowing emergency personnel to enter the facility due to “family being problematic”.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: David CuevasTELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 18-AS-20191011155501
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: PARADISE GUEST RANCH
FACILITY NUMBER: 330910554
VISIT DATE: 09/29/2021
NARRATIVE
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In addition, Staff #1 (S1), Licensee, was not available for questions and support at the time of incident. Interviews also revealed that S3 was not associated or fingerprint cleared to work at the facility but felt that since S3 was the son of the Licensee S3 could provided direction to S2. Still, S2 self disclosed that since R1 had a DO Not Resuscitate order (NDR) the resident could not leave the facility, as such S3 tried to stop emergency services from being provided and tried to stop the resident from leaving the facility. Furthermore, it was revealed that S3 visits the facility once or twice a week.

As such this department deems the allegation of, Staff did not allow emergency medical personnel access to resident’s room to be SUBSTANTIATED, A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted with Licensee, Connie Vasquez, were a copy of this report LIC 9099, LIC 9099 D, and appeal rights were provided.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: David CuevasTELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 18-AS-20191011155501
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PARADISE GUEST RANCH
FACILITY NUMBER: 330910554
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/13/2021
Section Cited
HSC
1569.269(2)
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(a) Residents of residential care facilities for the elderly shall have all of the following rights:
(2) To be granted a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups. This requirement was not met evidence by, S3 intervening and attemping to stop medical providers response while R1's family was visiting.
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Licensee will train staff regarding the proper procedures for allowing medical responders to enter residents room when family or residents call for an emergency by 10/13/21.
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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: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: David CuevasTELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/11/2019 and conducted by Evaluator David Cuevas
COMPLAINT CONTROL NUMBER: 18-AS-20191011155501

FACILITY NAME:PARADISE GUEST RANCHFACILITY NUMBER:
330910554
ADMINISTRATOR:VASQUEZ, CONNIEFACILITY TYPE:
740
ADDRESS:19150 KRIS ROADTELEPHONE:
(760) 329-8905
CITY:SKY VALLEYSTATE: CAZIP CODE:
92241
CAPACITY:6CENSUS: 4DATE:
09/29/2021
UNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Licensee, Connie VazquesTIME COMPLETED:
10:50 AM
ALLEGATION(S):
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Facility placed resident on hospice without authorization from resident's responsible person.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) David Cuevas conducted an unannounced visit to the facility above to deliver findings for complaint control #18-AS-20191011155501. LPA identified self and informed Licensee, Connie Vazques of the purpose of visit.
During the investigation process, LPA conducted facility file review, interviewed: staff, residents, and witnesses, and collected pertinent documents.

Regarding allegation # 3: Facility placed resident on hospice without authorization from resident's responsible person.

Based on resident #1 (R1’s) file review, interviews, and examination of pertinent documentation. It was determined that hospice orders were requested by R1’s primary physician. Additionally, hospice agreement shows responsible party to have signed and agreed to hospice and home health services for R1.


Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: David CuevasTELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 18-AS-20191011155501
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: PARADISE GUEST RANCH
FACILITY NUMBER: 330910554
VISIT DATE: 09/29/2021
NARRATIVE
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As such this department deems the allegation of, Facility placed resident on hospice without authorization from resident's responsible person to be UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

An exit interview was conducted with Licensee, Connie Vasquez, were a copy of this report was reviewed and provided.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: David CuevasTELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 7