330910554-12-3-2021-18-AS-NBRN-C9HSYR-20211208131756

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 330910554
Report Date: 11/08/2021
Date Signed: 12/03/2021 01:21:25 PM

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
04/06/2021 and conducted by Evaluator Shaunte Henry

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210406112722

FACILITY NAME:	PARADISE GUEST RANCH		FACILITY NUMBER:	330910554
ADMINISTRATOR:	VASQUEZ, CONNIE		FACILITY TYPE:	740
ADDRESS:	19150 KRIS ROAD		TELEPHONE:	(760) 329-8905
CITY:	SKY VALLEY	STATE: CA	ZIP CODE:	92241
CAPACITY:	6	CENSUS:	DATE:	11/08/2021
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Connie Vasquez, licensee/administrator		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Resident sustained unexplained injuries while in care.
Facility staff locks resident in his room.
Facility staff are not assisting resident with ADLs.

INVESTIGATION FINDINGS:

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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 Connie Vasquez, explained the nature of the visit and was granted entry into the facility.

The investigation, which consisted on interviews and observation revealed the following:
Information provided during interviews was conflicting and did not provide a solid basis to substantiate the above allegations. Staff interviews revealed that Resident 1 (R1) has very thin and frail skin, which is subject to easily sustaining minor skin tears, etc. Staff denied causing injuries to R1. Staff interviews also revealed that R1 locks themself in their room and has a hard time unlocking the door.

***continued on LIC 9099C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Shaunte Henry	TELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021

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 18-AS-20210406112722

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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*** Continued from LIC 9099***

Staff deny locking R1 in their room. Staff interviews also revealed that R1's change in condition has resulted in R1 receiving a lot assistance with activities of daily living (ADL)s on a daily basis. During an interview with Resident 2 (R2), it was reported that they have never been locked in their room. R2 reported that they have never sustained any injuries caused by staff. R2 also started that staff assist them with their ADLs. An interview with Resident 3 (R3) did not yield any pertinent information due to R3's altered mental status.

Although the allegations 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 was discussed with and provided to the licensee.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Shaunte Henry	TELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021

LIC9099 (FAS) - (06/04)

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