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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397005829
Report Date: 03/05/2025
Date Signed: 03/05/2025 03:48:05 PM

Substantiated


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
12/23/2024 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20241223102104
FACILITY NAME:PARADISE RESIDENTIAL CAREFACILITY NUMBER:
397005829
ADMINISTRATOR:ADA P. OSUKAFACILITY TYPE:
735
ADDRESS:2673 EAST JUNCTION DRIVETELEPHONE:
(209) 910-0900
CITY:MANTECASTATE: CAZIP CODE:
95336
CAPACITY:6CENSUS: 4DATE:
03/05/2025
UNANNOUNCEDTIME BEGAN:
10:27 AM
MET WITH:Ada P OsukaTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Violation of resdient rights
INVESTIGATION FINDINGS:
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On 3/5/2025 at 10:27am, Licensing Program Analysts (LPAs) Michael Bilger and Noel Wolf Petersen arrived unannounced to deliver and discuss findings for the allegation noted above. LPA met Administrator Ada Osuka and explained the purpose of the visit. During this investigation, LPA conducted interview with three staff members and one resident. LPA also reviewed facility file documentation including staff schedule, individual program plans (IPPs) for resident1 (R1) and R2, incident reports, needs and services plans, and physician’s reports. LPA also conducted a facility observation on 3-5-25 and reviewed a police report associated with the above allegations.
Allegation: Violation of resident rights. LPA conducted interviews and record reviews as stated above. Based on interviews and record reviews, it was revealed that on 12-18-2024 at approximately 11:45pm, a staff member was doing rounds. When staff member entered room of R2, staff observed R1 running into the bathroom belonging to R2.

{Cont. on 9099C}
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2025
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 5
Control Number 27-AS-20241223102104
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/14/2025
Section Cited
CCR
80072(a)(2)
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80072 Personal Rights (a)(2). (a) …each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful, and comfortable accommodations…This requirement was not met as evidenced by:
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Licensee to ensure completed staff training on resident rights. Proof of completed training to be sent to LPA by POC due date.
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Based on interviews and record reviews, R1 entered R2’s room without permission due to inappropriate level of staff supervision. This posed a potential health, safety, and resident rights risk to residents 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.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20241223102104
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: 03/05/2025
NARRATIVE
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Staff member then redirected R1 and informed R1 he was not to go into other bedrooms. Interviews conducted revealed R1 did not have permission to enter R2’s room. Additionally, it was determined that staff did not provide appropriate level of supervision necessary to prevent R1 from entering R2’s room. As a result, there is a preponderance of evidence to conclude resident rights were violated, therefore, this allegation is SUBSTANTIATED.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5