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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604395
Report Date: 01/02/2024
Date Signed: 01/02/2024 02:45:45 PM

Document Has Been Signed on 01/02/2024 02:45 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:PARADISE TRINITY HOME #2FACILITY NUMBER:
374604395
ADMINISTRATOR:ALCANTARA, RAY NEILFACILITY TYPE:
735
ADDRESS:9972 JAVELIN WAYTELEPHONE:
(619) 278-1811
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY: 4CENSUS: 2DATE:
01/02/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:DSP Estela Cruz and Administrator Ray Neil AlcantaraTIME COMPLETED:
02:55 PM
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with DSP Estela Cruz. LPA then met and discussed the purpose of the visit with Administrator Ray Neil Alcantara, who arrived later during the visit.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 12/27/2023). According to the LIC624: on 12/25/2023, Client #1 (C1) eloped from the facility (left without staff supervision). [See LIC 811 Confidential Names List for a description of person identifiers used.]

During today’s visit, LPA performed a brief facility tour and welfare check. At the time of LPA’s site visit, C1 had not yet returned to the facility. The other client in care, Client #2 (C2), was verified safe. LPA reviewed and collected copies of pertinent client records and audited clients' personal & incidental (P&I) cash and accounting records. LPA also interviewed relevant staff.

According to their latest LIC602 Physician’s Report (dated 03/29/2023), C1 was diagnosed with Mild Intellectual Disability and Unspecified Schizophrenic Disorder, and their doctor determined that they were not able to safely leave the facility unassisted.

According to Licensee’s general written Absentee Notification Plan, if a client is suspected to be missing, staff must immediately notify the facility’s licensee or administrator. If the client is not found after two (2) hours of searching, staff must notify local law enforcement for assistance. LPA observed that licensee’s general Absentee Notification Plan was not part of C1’s specific Needs and Services Plan, as was required.

[CONTINUED ON LIC 809-C,1 of 2]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 01/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 TRINITY HOME #2
FACILITY NUMBER: 374604395
VISIT DATE: 01/02/2024
NARRATIVE
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[CONTINUED FROM LIC 809]

According to the LIC624, and corroborated by staff interviews: On 12/24/2023, Staff #1 (S1) last observed C1 inside their bedroom around 9:15 PM. On 12/25/2023 around 6:30 AM, there was a shift change [i.e., S1 was relieved, and Staff #2 (S2) took over care and supervision]. Around 8:00 AM, S2 realized that C1 was not present inside the facility. Neither S1 nor S2 saw or heard C1 leave, and neither S1 nor S2 checked on C1 or checked C1’s bedroom during shift change. S2 immediately alerted facility managers, who searched the surrounding areas, unsuccessfully. Around 11:30 AM, Licensee’s staff first notified local law enforcement.

Records and staff interviews also revealed: On 12/24/2023, S1 opened the facility’s locked closet where both clients’ P&I monies are kept. S1 briefly left C1 unattended there after C1 asked to look at their own cash, but S1 did not secure C2’s cash before stepping away. When S1 returned to the closet, they did not ascertain if C1 withdrew any money, and did not verify that the cash on hand matched licensee’s accounting records. During today’s site visit, LPA observed that for both C1 and C2, the actual cash on hand did not match those clients’ ledgers.

According to C1’s Client Placement Referral document from San Diego Regional Center (SDRC), which was in Licensee’s possession, C1 was evicted from their prior facility due to an elopement incident there on 01/22023. SDRC records indicated C1 had other prior elopements, too. During today’s visit, LPA observed, and staff interview confirmed, that the Licensee did not equip its exterior doors at the facility with auditory staff alert devices.

A preponderance of evidence exists to show during the time frame of the incident: a) Licensee’s staff did not provide needed observation/supervision to C1; b) Licensee did not equip perimeter doors with staff alert devices despite having constructive knowledge of C1’s elopement risk; c) Licensee did not maintain an Absentee Notification Plan as part of the C1’s Needs and Services Plan and precisely follow it; and, d) Licensee did not safeguard client cash resources (which were entrusted to them and kept on the facility premises) as required.

[CONTINUED ON LIC 809-C, 2 of 2]
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 01/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2024
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 TRINITY HOME #2
FACILITY NUMBER: 374604395
VISIT DATE: 01/02/2024
NARRATIVE
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[CONTINUED FROM LIC 809-C, 1 of 2]

Three (3) deficiencies were cited per California Code of Regulations, Title 22, and one (1) deficiency was cited per California Health and Safety Code (refer to the attached LIC 809-D pages). Plans of Correction were jointly developed with the licensee.

An exit interview was conducted with Alcantara, to whom a copy of this report, the LIC809-D pages, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 01/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 01/02/2024 02:45 PM - It Cannot Be Edited


Created By: Dang Nguyen On 01/02/2024 at 02:34 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: PARADISE TRINITY HOME #2
FACILITY NUMBER: 374604395

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/01/2024
Section Cited
CCR
80078(a)

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80078 Responsibility for Providing Care and Supervision: “(a) The licensee shall provide care and supervision as necessary to meet the client’s needs.” This requirement was not met, as evidenced by:
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Licensee agreed to retrain its direct care staff on expectations regarding the frequency of visual checks on clients during shifts and performing visual checks on clients during shift change. Licensee agreed to E-mail LPA a copy of the training sign in sheet, by the POC due date.
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Based on records and interviews, during the incident in question, Licensee’s staff (S1 and S2) did not provide supervision necessary to meet the needs of 1 of 2 clients (C1). This posed a potential health and safety risk to persons in care.
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Type B
02/01/2024
Section Cited
CCR80077.3(a)

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80077.3 Care for Clients Who Lack Hazard Awareness or Impulse Control: “(a) If a client requires protective supervision because of running/wandering away, supervision may be enhanced by…installing operational bells, buzzers, or other auditory devices on exterior doors to alert staff when the door is opened.” This requirement was not met, as evidenced by:
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Licensee agreed to purchase and install door chimes for each of its three (3) perimeter exit doors. Licensee agreed to send LPA videos of these devices in place and audibly working, by the POC due date.
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Based on records and interviews, Licensee had constructive knowledge that 1 of 2 clients (C1) required protective supervision because of running/wandering away, but Licensee did not install auditory devices on exterior doors to alert staff when such doors are opened. This posed a potential safety risk to persons in care.
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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 Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 01/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/02/2024


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Document Has Been Signed on 01/31/2024 01:17 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 01/31/2024 01:16 PM


Created By: Dang Nguyen On 01/02/2024 at 02:39 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 TRINITY HOME #2
FACILITY NUMBER: 374604395

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/01/2024
Section Cited
HSC
1507.15

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1507.15 Absentee notification plan for missing residents or participants: “Every community care facility that provides adult residential care… shall…develop and comply with an absentee notification plan for each resident... The plan shall be part of the written Needs and Services Plan [and] shall include…a requirement that an administrator of the facility, or his or her designee, inform the resident’s…authorized representative when that resident…is missing from the facility and the circumstances…in which [they]…shall notify local law enforcement…”
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Licensee agreed to update its existing Absentee Notification Plan/policy, to place a copy of the plan in each client’s care binder beside the Needs and Services Plan, and to train its staff on the plan. Licensee agreed to E-mail the updated Absentee Notification Plan and the training sign-in sheet to LPA, by the POC due date.
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This requirement was not met, as evidenced by: Based on records and interviews, for 1 of 2 clients (C1), the licensee did not comply with its absentee notification plan and maintain this plan as part of the clients’ Needs and Services Plan. This posed a potential safety risk to persons in care.
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Type B
02/01/2024
Section Cited
CCR80026(j)

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80026 Safeguards for Cash Resources, Personal Property, and Valuables of Residents: “(j) Cash resources entrusted to the licensee and kept on the facility premises, shall be kept in a locked and secure location.” This requirement was not met, as evidenced by:
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Licensee agreed to contribute monies, as needed, to ensure that C1 and C2 both have cash on hand which matches the latest entry in each of these clients’ LIC421 ledger. Licensee agreed to self-audit clients’ LIC421 ledgers monthly, for accuracy. Licensee agreed to train its staff to expectations regarding continuous supervision of and accurate, real-time accounting of any client cash entrusted to its care at the facility premises. Licensee agreed to submit the training sign-in sheet to LPA, by the POC due date.
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Based on records and interviews: Licensee did not ensure that for 1 of 2 clients (C2), cash resources which were entrusted to the licensee and kept on the facility premises were kept locked and/or secure. This posed a potential personal rights violation to persons in care.
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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 Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 01/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/02/2024


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