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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405802288
Report Date: 07/21/2022
Date Signed: 07/21/2022 12:42:30 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/07/2022 and conducted by Evaluator Jeannette Olson
COMPLAINT CONTROL NUMBER: 29-AS-20220107115051
FACILITY NAME:PARADISE VALLEY CAREFACILITY NUMBER:
405802288
ADMINISTRATOR:CAROLA WHITEFACILITY TYPE:
740
ADDRESS:9525 GALLINA CTTELEPHONE:
(805) 468-4141
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY:15CENSUS: 8DATE:
07/21/2022
UNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Carola White, AdministratorTIME COMPLETED:
12:55 PM
ALLEGATION(S):
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Facility staff is not following COVID-19 guidelines.
Facility is in disrepair.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Olson conducted an unannounced complaint visit to issue final findings. LPA Diaz conducted the initial 10-day complaint visit on 1/12/22. LPA Olson met with Carola White, Administrator and explained the purpose of the visit.

On the allegation: Facility staff is not following COVID-19 guidelines. On 1/6/22 at around 12:15pm a credible witness observed Staff 1 (S1) wearing their mask below their nose while providing a resident care. An interview with Administrator revealed the staff’s mask slipped down, but the staff had soiled hands after assisting a resident in the bathroom and could not pull up the mask. The staff pulled up their mask as soon as their hands were cleaned. Based on a credible witness, this allegation is deemed substantiated and a Technical Violation was issued for not following COVID guidelines related to masks.

Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022
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 29-AS-20220107115051
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: PARADISE VALLEY CARE
FACILITY NUMBER: 405802288
VISIT DATE: 07/21/2022
NARRATIVE
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On the allegation: Facility is in disrepair. It was alleged the numeric code alarm pad inside the front door of the facility was not working, because the battery had died. Administrator stated this occurred during a COVID-19 outbreak, and she had stayed away from the facility due to health issues. Administrator stated staff attempted to replace the batteries, but there was an issue because the unit took 4 batteries even though it appeared to only use 2 batteries, and staff had only replaced 2 batteries. Eventually, the administrator went to the facility on 1/6/2022 to change the battery and ensure the door was operational. Other doors in the facility were always operational. Based on a credible witness and Administrator Interview this allegation is deemed substantiated at this time.

Exit interview conducted, deficiencies cited on 9099-D, appeal rights and report emailed to Administrator/ Licensee.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 29-AS-20220107115051
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PARADISE VALLEY CARE
FACILITY NUMBER: 405802288
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/21/2022
Section Cited
CCR
87303(a)
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87303(a) Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement was not as evidenced by:
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Administrator went to the facility on 1/6/22 to change the battery and ensure the door was operational.
The POC was cleared during the visit
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Based on interviews and observation from a credible witness, the licensee did not ensure that the front door worked, which posed a potential health and 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: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/07/2022 and conducted by Evaluator Jeannette Olson
COMPLAINT CONTROL NUMBER: 29-AS-20220107115051

FACILITY NAME:PARADISE VALLEY CAREFACILITY NUMBER:
405802288
ADMINISTRATOR:CAROLA WHITEFACILITY TYPE:
740
ADDRESS:9525 GALLINA CTTELEPHONE:
(805) 468-4141
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY:15CENSUS: 8DATE:
07/21/2022
UNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Carola White, AdministratorTIME COMPLETED:
12:55 PM
ALLEGATION(S):
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Facility does not have adequate food/water supplies.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Olson conducted an unannounced complaint visit to issue final findings. LPA Diaz conducted the initial 10-day complaint visit on 1/12/2022. LPA Olson met with Carola White, Administrator and explained the purpose of the visit.

On the allegation: Facility does not have adequate food/water supplies. The reporting party stated that there was not food present in the facility that was listed on the weekly menu and the food supply was generally low. On 1/6/2022, the Administrator emailed CCL pictures of adequate food and water supplies, including perishable and nonperishable foods. Due to photographs provided, this allegation is deemed unsubstantiated at this time.

Exit interview conducted, report emailed to Administrator/Licensee.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022
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