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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 330910554
Report Date: 11/08/2021
Date Signed: 11/08/2021 11:30:25 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 MS29-26
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/06/2020 and conducted by Evaluator Shaunte Henry
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200706150734
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: 6DATE:
11/08/2021
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Connie Vasquez, licenseeTIME COMPLETED:
11:45 AM
ALLEGATION(S):
1
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8
9
Staff Failed to provide resident with appropriate linen
Staff failed to keep a sanitary environment for resident while in care
INVESTIGATION FINDINGS:
1
2
3
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5
6
7
8
9
10
11
12
13
On 11/8/21, Licensing Program Analyst (LPA) Shaunte Henry conducted an unannounced visit for the purpose of delivering the findings to the above allegations. The LPA met with licensee Connie Vasquez, explained the nature of the allegations and was granted entry into the facility.

The investigation consisted of a facility tour, interviews and document review. The facility tour revealed all of the resident bedrooms and common areas were clean and orderly. R1's bedroom had the required linen and there was extra linen available to all residents. Interviews revealed that R1 is provided the necessary hygiene items and the necessary linen for their bed. An interview with the licensee revealed that R1 does wear diapers and is changed and cleaned regularly.
***Continued on 9099C***
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Edna MusokeTELEPHONE: (951) 248-0336
LICENSING EVALUATOR NAME: Shaunte HenryTELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021
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 2
Control Number 18-AS-20200706150734
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: 11/08/2021
NARRATIVE
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32
 ***Continued from 9099***

Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED at this time. An exit interview was conducted where this report and LIC 811 were provided to the licensee.

SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Shaunte HenryTELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2