445202559-5-28-2021-26-AS-KHOS-C3TLDE-20210609083949

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445202559
Report Date: 05/27/2021
Date Signed: 05/28/2021 01:33:06 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
07/10/2020 and conducted by Evaluator Yatfai Ng

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20200710103559

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: 22	DATE:	05/27/2021
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Erin Wiley		TIME COMPLETED:	04:20 PM

ALLEGATION(S):

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Facility did not issue a refund.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Yatfai Eric Ng and Ryker Heberle conducted an unannounced subsequent complaint investigation to deliver the investigation finding. LPAs met with Administrator Erin Wiley.

An initial unannounced tele-investigation was conducted by LPA Ng on 7/16/2020. LPA virtually toured the facility. LPA Ng interviewed 1 staff and obtained a copy of admission agreement (AD) and a copy of payment refund.

On 7/16/2020, LPA Ng interviewed 1 staff (administrator). 1 out of 1 staff stated the refund policy of the facility states that a prorated refund would be issued only if the resident passes away.

Unfounded

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: 05/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2021

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-20200710103559

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: 05/27/2021

NARRATIVE

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Based on record review, the refund policy in AD stated:
A. The agreement must indicate whether or not all, or any portion, of a payment will be refunded.
B. Refunds will be granted as follows: upon the death of a resident/prorated per Licensing Regulations.
C. If the resident leaves the facility temporarily, the holding rate for his/her room is FULL RENT per day. The total monthly rate set forth in the admission agreement WILL NOT be prorated on a daily basis upon the resident’s admission to, or permanent departure from, the facility during the month. Initialed (Resident or Responsible Person’s Initials)

Payment refund receipt indicated the family of a resident (R2) received a partial refund in June 2020, which matched the record in the Department that R2 passed away in May 2020.

On 7/16/2020, LPA Ng interviewed the reporting party (RP). RP stated R1 was transferred to a skilled nursing facility. Based on the fact that resident left the facility temporarily, the facility was charging for the holding rate which will not be prorated during the month per AD. Additionally, R1 did not give a 30-day notice of intent to vacate to the facility.

Based on interviews and record review, the Department had found that the above allegation was UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis.

This report was reviewed with Administrator. A copy of this report was provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai Ng	TELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2021

LIC9099 (FAS) - (06/04)

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