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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374601395
Report Date: 11/21/2022
Date Signed: 11/23/2022 02:21:06 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/18/2022 and conducted by Evaluator Amy Domingo
COMPLAINT CONTROL NUMBER: 08-AS-20221118093115
FACILITY NAME:PARADISE VALLEY MANORFACILITY NUMBER:
374601395
ADMINISTRATOR:AARON BURRUPFACILITY TYPE:
741
ADDRESS:2575 E. EIGHTH STREETTELEPHONE:
(619) 470-6700
CITY:NATIONAL CITYSTATE: CAZIP CODE:
91950
CAPACITY:50CENSUS: 39DATE:
11/21/2022
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Cecilia Salomon, Wellnes DirectorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Facility staff failed to provide necessary medical care
Facility staff illegally evicted resident from the facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to commence a complaint investigation. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Cecilia Salomon, Wellness Director.

The Department’s investigation consisted of interviews and facility records review. It was alleged that the facility staff unlawfully discharged a resident and that facility staff did not ensure that a resident received medical treatment while in care. LPA requested pertinent information for the month of November 2022. A review of records and interview with the Director revealed that the resident in question has not lived at the facility licensed by the Department. The facility the resident resided in is not within the Community Care Licensing Division's jurisdiction. As such, the Department has no jurisdiction to investigate. Therefore, the allegations are determined to be unfounded, which means that the allegations are false, could not have

(Continued on LIC9099C)
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 767-2330
LICENSING EVALUATOR NAME: Amy DomingoTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2022
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 08-AS-20221118093115
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: PARADISE VALLEY MANOR
FACILITY NUMBER: 374601395
VISIT DATE: 11/21/2022
NARRATIVE
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happened, and/or are without a reasonable basis.

An exit interview was conducted, and a copy of this report and Licensee Rights LIC 9058 (3/22) were left with the Wellness Director, whose signature on the form confirms receipt of these documents.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 767-2330
LICENSING EVALUATOR NAME: Amy DomingoTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2