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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 360909246
Report Date: 10/20/2023
Date Signed: 10/20/2023 02:36:12 PM

Unsubstantiated


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
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/28/2023 and conducted by Evaluator Rayshaun Nickolas
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230828124201
FACILITY NAME:PADUA VILLAGE, INC.FACILITY NUMBER:
360909246
ADMINISTRATOR:SHAWN F. BARRACKSFACILITY TYPE:
735
ADDRESS:11981 MIDWAY RD.TELEPHONE:
(760) 248-6245
CITY:LUCERNE VALLEYSTATE: CAZIP CODE:
92356
CAPACITY:26CENSUS: 24DATE:
10/20/2023
UNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Shawn Barracks, administratorTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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9
Licensee does not ensure the facility has working toilets.
Licensee does not ensure facility roof is in good repair.
Facility staff are not assisting residents with bathing.
Facility staff do not ensure facility has a washer and dryer machine in good repair.
Licensee does not ensure faucets used for personal care deliver water at a safe temperature.
Facility staff are not keeping the facility at a comfortable room temperature for residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rayshaun Nickolas arrived at the facility unannounced to deliver findings on the above allegations. LPA Nickolas met with administrator Shawn Barracks and explained the purpose of the visit. The investigation included facility tours, file reviews, and interviews with relevant parties.

Allegation #1: “Licensee does not ensure the facility has working toilets”. The allegation alleged that facility staff were instructed to fill a 5-gallon jug, carry it to the toilets to fill the tank, and manually flush the toilets. LPA Nickolas’ interviews with several facility staff members revealed that the toilets were not working but are working now. LPA Nickolas’ interviews with several residents revealed that the residents interviewed could not participate in the interview process, except for two (2) residents that denied this allegation. On August 30, 2023, during LPA Nickolas’ initial complaint investigation visit, LPA Nickolas discovered that the toilets were inoperable. However, a representative from a septic company was working at the facility to fix the problem, and all toilets were operable before LPA Nickolas left the facility. During today’s visit, LPA Nickolas conducted a subsequent facility tour and confirmed that all the toilets were working. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023
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 3
Control Number 56-AS-20230828124201
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
, CA 92507
FACILITY NAME: PADUA VILLAGE, INC.
FACILITY NUMBER: 360909246
VISIT DATE: 10/20/2023
NARRATIVE
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Allegation #2 “Licensee does not ensure facility roof is in good repair”. The allegation alleged a leak in resident #1 (R1) room and the general dining room. LPA Nickolas’ interviews with several facility staff members revealed that they confirmed this allegation. However, all staff interviewed confirmed that all necessary repairs were made. LPA Nickolas’ interviews with several residents revealed that the residents interviewed could not participate in the interview process or could not provide information about this allegation. On August 30, 2023, during LPA Nickolas’ initial complaint investigation visit, LPA Nickolas observed staff repairing the ceiling in R1’s room. Also, during that initial investigation visit, LPA Nickolas observed a large bowl in the dining area, collecting the water from the leak. During today’s visit, LPA Nickolas conducted a subsequent facility tour and confirmed no leaks in R1’s room or the dining area. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.

Allegation #3: "Facility staff are not assisting residents with bathing". The allegation alleged that resident #2 (R2), resident #3 (R3), and resident #4 (R4) had not had a shower in seven (7) days. LPA Nickolas' interviews with several facility staff members revealed that all interviewed denied this allegation, except for one (1). LPA Nickolas' interviews with R2, R3, and R4 revealed that they could not participate in the interview process. However, LPA Nickolas' observations of R2, R3, and R4 revealed no evidence that the residents had not showered in seven (7) days. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.

Allegation #4 “Facility staff do not ensure facility has a washer and dryer machine in good repair”. The allegation alleged that staff were instructed to dry the facility’s laundry to the laundromat. The allegation also alleged that the washer and dryer are in disrepair. LPA Nickolas’ interviews with several facility staff members revealed that they confirmed this allegation. However, all staff interviewed confirmed that the washer and dryer are working. LPA Nickolas’s interviews with several residents revealed that the residents interviewed could not participate in the interview process except for two (2) residents. One (1) of the two (2) residents could not confirm or deny this allegation, while the other denied it. During today’s visit, LPA Nickolas conducted a subsequent facility tour, which revealed that the facility’s washers and dryers are in good repair. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20230828124201
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
, CA 92507
FACILITY NAME: PADUA VILLAGE, INC.
FACILITY NUMBER: 360909246
VISIT DATE: 10/20/2023
NARRATIVE
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Allegation #5 “Licensee does not ensure faucets used for personal care deliver water at a safe temperature”. The allegation alleged that the water temperature in the faucet was too hot, resulting in R1 scolding their left wrist while washing their hands. LPA Nickolas’ interviews with several facility staff members revealed that all interviewed were unaware of this incident, except one (1). LPA Nickolas’ interviews with several residents revealed that the residents interviewed could not participate in the interview process, except for two (2) residents who denied that the water temperature in the faucets was too hot. On August 30, 2023, during LPA Nickolas’ initial complaint investigation visit, LPA Nickolas tested the water temperature of every sink at the facility, and the water temperatures were within regulatory requirements. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.

Allegation #6 “Facility staff are not keeping the facility at a comfortable room temperature for residents”. The allegation alleged that on August 2, 2023, the facility's indoor temperature was 80 degrees Fahrenheit when the outdoor temperature was 103 degrees Fahrenheit. LPA Nickolas' interviews with several facility staff members revealed that all interviewed denied this allegation, except for two (2) facility staff members. One (1) of the two (2) members of the facility staff stated it was too hot during that time, but it is fine now, while the other confirms this allegation. LPA Nickolas’ interviews with several residents revealed that the residents interviewed could not participate in the interview process, except for two (2) residents who denied this allegation. On August 30, 2023, during LPA Nickolas’ initial complaint investigation visit, LPA Nickolas observed that indoor facility temperatures ranged from 72 degrees to 77 degrees Fahrenheit. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.

A finding of Unsubstantiated means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted and copy of this report was provided.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3