397005829-5-14-2024-27-AS-LKIG-D5FURE-20240520154838

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 397005829
Report Date: 05/13/2024
Date Signed: 05/14/2024 05:04:13 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
03/01/2024 and conducted by Evaluator Charlie Yang

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20240301103031

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:	01:30 PM
MET WITH:	Elisama Vidot		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Lack of supervision resulted in resident on resident altercation with injury.

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 interviews, it was learned that facility resident, R1 and R2, were involved in an altercation that resulted in R2 having to go to the hospital. It was learned that R2 sustained four broken ribs as a result of this altercation.
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

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-20240301103031

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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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 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 on the date of the altercation, R1 arrived back to this facility already in a foul mood. R1 was looking to take out this foul mood and found a target in R2 who was sitting alone on the couch. Facility staff was present and instructed R2 to flee the area once it was observed that R1 was engaging in an outburst and physically seeking someone as a target.
It was learned that facility staff were present and able to remove R2 from the initial physical attempt but R1 continued to chase R2 which resulted in both of them stumbling over a chair. This resulted in R1 landing on top of R2 which caused R2 to sustain the (4) broken ribs.
It was learned that facility staff were present and tried to de-escalate the situation when it was observed that R1 was in a foul mood.
Based on the evidence obtained, the altercation was not a result of a lack of care or supervision by the facility staff. Staff sufficiently monitored the residents and took the necessary steps to provide medical attention after the injury was sustained.

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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