397005829-5-14-2024-27-AS-LKIG-D5FUS5-20240520154946

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 397005829
Report Date: 05/13/2024
Date Signed: 05/14/2024 06:10:33 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/19/2024 and conducted by Evaluator Charlie Yang

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20240319162632

FACILITY NAME:	PARADISE RESIDENTIAL CARE		FACILITY NUMBER:	397005829
ADMINISTRATOR:	ADA P. OSUKA		FACILITY TYPE:	735
ADDRESS:	2673 EAST JUNCTION DRIVE		TELEPHONE:	(209) 910-0900
CITY:	MANTECA	STATE: CA	ZIP CODE:	95336
CAPACITY:	6	CENSUS: 5	DATE:	05/13/2024
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Elisama Vidot		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Resident was physically restrained by single staff.

INVESTIGATION FINDINGS:

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Unannounced complaint visit made out to this facility on 05/13/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility house manager Elisama Vidot. This LPA requested that she go ahead and notify the facility designated Administrator, Ada Osuka, to inform her that CCL was present at this time.
A brief interview was conducted with the facility house manager at this time.
Current census was 5 residents.
The purpose of this visit was to deliver the findings of this investigation to this facility and its designated staff at this time.
Based on a review of the forms and documents conducted, it was learned that R1 was prone for outbursts and aggressive behaviors towards facility residents and staff as outlined in R1's most recent IPP. The facility
designated Administrator and facility staff were well aware of this and always maintained line of sight with R1 at all times.
It was learned that facility staff were also recently trained and updated for workplace violence and

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2024

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 27-AS-20240319162632

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PARADISE RESIDENTIAL CARE	FACILITY NUMBER: 397005829
	VISIT DATE: 05/13/2024

NARRATIVE

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de-escalation training. In addition, all facility staff providing care and supervision to the residents in care were trained in Professional Adult Crisis Training (Pro-Act).
It was learned that R1 would often times make up scenarios in R1's mind and tell them to other residents and facility staff depending on R1's mood. These scenarios and events in R1's mind were often times untrue even though R1 truly believed that they took place and were factual in nature.
It was learned that this took place if a certain individual performed something that was not to the liking of R1 on any particular date or time. R1 would then spin this emotion into an event, such as facility staff mishandling R1 physically, and attempt to spread it around to other facility residents and third party agencies.
Based on interviews conducted in regards to this behavior from R1, these allegations of physical harm or abuse would be recanted later on and a heartfelt apology would be given by R1 since it did not take place as stated by R1.

As a result of this investigation, this Department found the allegation to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegation may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred.

There were no deficiencies observed or cited during today's complaint visit at this time.

Exit Interview

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2024

LIC9099 (FAS) - (06/04)

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