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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435200921
Report Date: 08/19/2025
Date Signed: 08/19/2025 04:21:15 PM

Substantiated


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
06/27/2025 and conducted by Evaluator Simranjit Rai
COMPLAINT CONTROL NUMBER: 26-AS-20250627124639
FACILITY NAME:PARADISE MANOR 3FACILITY NUMBER:
435200921
ADMINISTRATOR:MIGUEL, LYNDAFACILITY TYPE:
735
ADDRESS:19147 MURIEL LANETELEPHONE:
(408) 257-2953
CITY:CUPERTINOSTATE: CAZIP CODE:
95014
CAPACITY:6CENSUS: 6DATE:
08/19/2025
UNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Licensee/Administrator, Lynda TIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff did not ensure that hazardous objects were inaccesible to clients.
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 the Administrator and stated the purpose of today’s visit.

On 6/27/2025, the Department received a complaint with the above allegation. On 6/30/2025, the Department conducted an initial investigation at the facility.

It was alleged that resident R1 had access to a pair of scissors in R1’s room.

On 6/30/2025, LPA Rai observed a pair of scissors in R1’s container filled with art supplies, such as pens, markers. R1’s container was taken out of R1’s room to present to LPA during the visit.

Continuation on LIC 9099-C, Page 1 of 2.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025
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 3
Control Number 26-AS-20250627124639
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: 08/19/2025
NARRATIVE
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Page 2 of 2.

On 6/30/2025, LPA Rai interviewed 3 staff (S1-S3). 3 Out of 3 staff stated a pair of scissors were in R1’s room and accessible to resident as R1 bought the items with his/her own money and wanted to keep the item in his/her room. S3 stated the staff had previously taken the scissors from R1, but R1 bought another pair of scissors and insisted on keeping the scissors in the room.

On 6/30/2025, LPA Rai attempted to speak with R1, but R1 refused to be interviewed at the time of the visit and stated R1 hid the scissors so facility staff would not be able to take it away from R1’s room.

Based on review of emails submitted from the San Andreas Regional Center’s service coordinator (SC) and R1’s responsible party, R1’s scissors are to remain with the facility staff and provided to R1 when R1 requests the item or the item is necessary for the project being conducted while staff are supervising the residents in care.

Based on review of previously submitted Incident Report from facility regarding incident involved R1 on 4/29/2025, R1 had cut herself/himself using scissors she/he purchased at a store. Per Report, the facility's preventative action plan was to remove sharp objects (scissors) from her/his belongings and R1 would tell staff when R1 needed to use them and will be supervised when using them.

Based on interviews and observation/inspection of the facility, the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 9099-D.
This report was reviewed with Administrator and a copy of the report was provided. Appeal Rights was provided.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 26-AS-20250627124639
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/20/2025
Section Cited
CCR
80087(g)
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80087 Buildings and Grounds (g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.
This requirement was not met as evidenced by:
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Licensee/Administrator stated to remove the item and ensure the item is inaccessible to residents in care by POC due date. Licensee/Administrator agreed and understood.
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Based on observation and interview, the licensee did not ensure an item, a pair of scissors, which posed a danger to resident R1 was inaccessble to resident which poses/posed an immediate Health, Safety, or Personal Rights 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.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3