445202559-9-10-2020-26-AS-SYIP-BTCNLQ-20200911103355

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445202559
Report Date: 09/09/2020
Date Signed: 09/10/2020 03:56:22 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
04/15/2020 and conducted by Evaluator Yatfai Ng

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20200415161911

FACILITY NAME:	PARADISE VILLA		FACILITY NUMBER:	445202559
ADMINISTRATOR:	ERIN ROSE WILEY		FACILITY TYPE:	740
ADDRESS:	2177 17TH AVENUE		TELEPHONE:	(831) 475-1380
CITY:	SANTA CRUZ	STATE: CA	ZIP CODE:	95062
CAPACITY:	58	CENSUS: 19	DATE:	09/09/2020
		UNANNOUNCED	TIME BEGAN:	11:39 AM
MET WITH:	Erin Rose Wiley		TIME COMPLETED:	11:43 AM

ALLEGATION(S):

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Lack of supervision resulting in a physical altercation between residents.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Yatfai Eric Ng conducted an unannounced subsequent tele-complaint investigation to deliver the investigation finding. Due to current COVID-19 situation, LPA virtually met with the Administrator Erin Rose Wiley.

An initial unannounced tele-investigation was conducted by LPA on 4/27/2020. LPA virtually toured the facility, interviewed 2 residents (R1 and R2) and 1 staff, and requested copies of physician’s reports and appraisal/needs and services plans.

1 out of 2 residents (R1) stated R2 was not known to R1 for being violent until the time of the incident. Although exact time was not remembered, it did not take long for the staff to come in to help R1 got out of the altercation. R2 who was lying on bed while being interviewed did not respond to LPA’s questions.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai Ng	TELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2020

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 26-AS-20200415161911

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: PARADISE VILLA	FACILITY NUMBER: 445202559
	VISIT DATE: 09/09/2020

NARRATIVE

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Per staff interview, on 4/27/2020, a staff (S2) was passing medication at night. S2 found the door of R1 and R2 barricaded. S2 knocked on the door to ask R1 or R2 to open the door; at the same time S2 heard R1 started calling for help. S2 then called another staff (S3) to assist. S2 and S3 then went inside to separate R2 from R1.

Between 4/22/2020 and 6/11/2020, LPA interviewed 1 case manager, 1 nurse, 3 additional staff, and 1 family member of R1 and R2. All of them stated R2 was not known to be violent. R2 never demonstrated any aggressive behaviors toward R1 or other people. Thus, there was no concern for R1 and R2 to be placed together in the same room. R2 was not observed or noted to be violent until the incident took place. It was initially believed that it would be safe to leave R2 with R1 by themselves. The family member stated R1 was happy that the staff helped and assisted R1 out of the altercation in around 2 minutes. The family member and R1 did not think there was a lack of supervision from the facility.

Based on record review, R1’s physician’s report dated 12/30/2019 noted R1 did not have suicidal/self-abuse mental condition. R1 also did not have mild cognitive impairment, dementia, inappropriate, or aggressive behavior. R2’s physician’s report dated 12/26/2019 noted that R2 had mild cognitive impairment, and low level confused/disoriented, but It was also noted that R2 did not have suicidal and self-abuse mental condition, and R2 did not have inappropriate or aggressive behavior. Both appraisal/needs and services plans did not indicate the need for supervision at all times.

Based on interviews and record review, the department has determined that the allegation was UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

This report was reviewed with the Administrator and a copy of this report was emailed to the Administrator for reference and for signature.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai Ng	TELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2020

LIC9099 (FAS) - (06/04)

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