435200921-7-30-2024-26-AS-KHOS-D8JQ2J-20240827114712

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435200921
Report Date: 07/30/2024
Date Signed: 07/30/2024 03:11:59 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/05/2022 and conducted by Evaluator Simranjit Rai

COMPLAINT CONTROL NUMBER: 26-AS-20220405135233

FACILITY NAME:	PARADISE MANOR 3		FACILITY NUMBER:	435200921
ADMINISTRATOR:	MIGUEL, LYNDA		FACILITY TYPE:	735
ADDRESS:	19147 MURIEL LANE		TELEPHONE:	(408) 257-2953
CITY:	CUPERTINO	STATE: CA	ZIP CODE:	95014
CAPACITY:	6	CENSUS: 6	DATE:	07/30/2024
		UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Caregiver, Maria Gabriel		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Facility staff hit a resident who sustained bruises on upper and lower extremities.
Resident has to ask staff permission when making calls.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with Caregiver, Maria Gabriel and stated the purpose of the visit.

On 4/5/2022, the Department received a complaint with the above allegations. On 4/12/2022, the Department conducted the initial investigation.

Continuation on LIC 809-C, Page 1 of 3.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024

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 3

Control Number 26-AS-20220405135233

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: PARADISE MANOR 3	FACILITY NUMBER: 435200921
	VISIT DATE: 07/30/2024

NARRATIVE

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Page 2 of 3.

Facility staff hit a resident who sustained bruises on upper and lower extremities.
It was alleged that the resident had bruises on legs and upper thighs which were caused by facility staff to harm the resident (R1).

On 4/3/2022, R1 attempted to leave the facility by the window located in the front of the facility. Based on review of Incident Reports submitted by Facility Licensee and Administrator, R1 did not want to go through the facility front door but R1 was trying to climb out of the facility window.

On 4/12/2022, the Department conducted an interview with ADM, who stated on 4/3/2022 R1 attempted to jump out of the facility window when staff tried to stop R1 by holding her arm. Based on interviews, 2 out of 2 staff stated the R1 was attempting to leave the facility by jumping through a facility window on the first floor and the staff were holding R1 back. They did not see staff hit R1, but staff was holding R1 back so R1 did not hurt themselves during the incident.

Based on R1’s Individual Program Plan 11/4/2021, R1 has a history of anger, self injurious behavior, and suicidal ideation.

On 5/22/2024, the Department conducted interviews of 2 staff (S1-S2) who stated on 4/3/2022, the staff were trying to redirect R1 to the front door and staff was trying to ensure R1’s safety by holding her arms and legs. The window is located on the first floor facing the main street and staff were present during the incident. S1 and S2 stated bruises may have formed during to the staff interacting with R1.

On 5/22/2024, the Department conducted interview with 1 resident (R2) who agreed to be interviewed. R2 stated the staff do not hurt the residents at the facility and they do assist residents by holding their hands and arm.

During the course of the investigation, R1 moved out of the facility and was unavailable to conduct an interview.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20220405135233

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: PARADISE MANOR 3	FACILITY NUMBER: 435200921
	VISIT DATE: 07/30/2024

NARRATIVE

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Page 3 of 3.

Resident has to ask staff permission when making calls.
It was alleged that R1 does not have access to a phone since resident’s conservator took resident’s cell phone away.

On 4/12/2022, the Department conducted an interview with ADM, who stated R1 can use the facility phone without restriction. ADM stated R1 had a cell phone in the past but R1 would call everyone, take pictures, and sent to R1’s boyfriend so R1’s conservator took the cell phone away.

On 5/22/2024, the Department conducted interviews 2 staff (S1-S2) who stated on staff do not restrict resident from using telephone at the facility. S1 stated R1 did have a cellphone which the R1’s responsible party took away from R1 but the facility telephone was always available to use.

On 5/22/2024, the Department conducted interview with 1 resident (R2) who agreed to be interviewed. R2 stated the staff do not restrict residents from using telephone at the facility.

During the course of this investigation, LPA Rai has observed the facility telephone in good repair and available to use at the facility for the residents.

During the course of the investigation, R1 moved out of the facility and was unavailable to conduct an interview.

Based on the interviews conducted with clients and staff and based on observation and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Caregiver, Maria Gabriel and a copy of the report was provided.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024

LIC9099 (FAS) - (06/04)

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