<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374601395
Report Date: 08/31/2023
Date Signed: 08/31/2023 02:04:04 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
06/12/2023 and conducted by Evaluator Sabel Martinez
COMPLAINT CONTROL NUMBER: 08-AS-20230612083454
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: 40DATE:
08/31/2023
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Wellness Director, Cecy SalomonTIME COMPLETED:
02:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff handled resident in a rough manner.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced complaint investigation visit. The LPA introduced himself and disclosed the purpose of the visit to Wellness Director, Cecy Salomon.

Throughout the investigation, the Department secured pertinent records and conducted interviews with external and internal sources, including staff and residents.

It was alleged staff handled a resident in a rough manner. It was reported to the Department Staff # 1 (S1) had roughly assisted Resident #1 (R1) during incontinence care and while assisting a resident in repositioning in bed. Interviews with multiple internal sources corroborated staff had at times used force that was considered rough. One source stated there was no gentle way of assisting R1, and staff had to use force. A different source mentioned S1, at least on one occasion, had rushed a resident and roughly assisted the resident in dressing.
(See LIC 9099-C for continuation of report.)
Substantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
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 4
Control Number 08-AS-20230612083454
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: PARADISE VALLEY MANOR
FACILITY NUMBER: 374601395
VISIT DATE: 08/31/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Although, external sources did not disclose any similar concerns, there was a preponderance of evidence to prove the alleged violation occurred. Therefore, the allegation was substantiated and a deficiency cited in an LIC 9099-D. A plan of correction was jointly formulated with Wellness Director Salomon.

An exit interview was conducted with Salomon, to whom a copy of this report, LIC 9099D, LIC 811 Confidential names list and Licensee/Appeals Rights (LIC 9058) were provided.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 08-AS-20230612083454
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: PARADISE VALLEY MANOR
FACILITY NUMBER: 374601395
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/31/2023
Section Cited
CCR
87468.2(a)(8)
1
2
3
4
5
6
7
87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:(8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Wellness Director agreed to provide in service training to all staff, inlcuding S1, on resident rights and handling with care.
8
9
10
11
12
13
14
Based on interviews, the licensee did not ensure residents, including R1, were free from neglect, which posed a potential health, safety and personal rights risk to 40 of 40 residents in care.
8
9
10
11
12
13
14
Wellness Director agreed to submit documentation including training date and log of participants by 9/15/23.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Lizzette TellezTELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
06/12/2023 and conducted by Evaluator Sabel Martinez
COMPLAINT CONTROL NUMBER: 08-AS-20230612083454

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: 40DATE:
08/31/2023
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Wellness Director, Cecy SalomonTIME COMPLETED:
02:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff hit resident in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced complaint investigation visit. The LPA introduced himself and disclosed the purpose of the visit to Wellness Director, Cecy Salomon.

Throughout the investigation, the Department secured pertinent records and conducted interviews with staff, residents and external sources.

It was alleged staff hit a resident in care. It was reported to the Department a staff member had flicked a resident’s face. Interviews with staff, residents, and external sources did not reveal any concerns regarding staff interaction with residents, that staff had hit residents in care, nor residents flicked by staff. Although the alleged violation could have happened, there was not a preponderance of evidence to prove it had happened. Therefore, the allegation was Unsubstantiated.

An exit interview was conducted with Salomon, to whom a copy of this report, and Licensee/Appeals Rights (LIC 9058) were provided.
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4