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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 445202559
Report Date: 11/12/2021
Date Signed: 11/12/2021 05:11:43 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
06/04/2021 and conducted by Evaluator Ryker Heberle
COMPLAINT CONTROL NUMBER: 26-AS-20210604091710
FACILITY NAME:PARADISE VILLAFACILITY NUMBER:
445202559
ADMINISTRATOR:ERIN ROSE WILEYFACILITY TYPE:
740
ADDRESS:2177 17TH AVENUETELEPHONE:
(831) 475-1380
CITY:SANTA CRUZSTATE: CAZIP CODE:
95062
CAPACITY:58CENSUS: 30DATE:
11/12/2021
UNANNOUNCEDTIME BEGAN:
02:12 PM
MET WITH:Erin WileyTIME COMPLETED:
05:11 PM
ALLEGATION(S):
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Staff are not meeting resident's hygiene needs
Staff are not following Dr. orders
Staff do not treat residents with dignity
Staff did not tell family members about covid outbreaks at the facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ryker Heberle conducted an unannounced complaint visit and met with Administrator, Erin Wiley, to deliver investigation findings.

On June 4th, 2021, the Department received the above allegations against the facility and conducted an initial complaint investigation visit on June 14th, 2021 to tour the facility, interview staff and residents, and request facility records.

During interviews with residents at the facility 2 out of 9 residents interviewed stated that they did not believe that their needs were being met at the facility. 2 out of 9 residents interviewed stated that they had been personally disrespected by staff on numerous occasions. One resident stated that she only receives 1 shower per week and would prefer to have more showers.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021
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 6
Control Number 26-AS-20210604091710
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: 11/12/2021
NARRATIVE
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In interviews with visitors to the facility, 1 out of 5 visitors stated that they had personally witnessed staff treating residents at the facility too roughly. In interviews with facility staff members, 5 out of 11 staff members interviewed stated that they had personally witnessed caregivers working in the facility mistreat residents either physically or emotionally. One staff member indicated that a resident with special showering needs (R1) was only receiving assistance with those needs once per week. An additional staff member indicated that R1 was only receiving showers twice per week. Review of R1's record indicate that R1 requires use of medical shampoo three times per week.

During consultation of public health records, LPA observed that 2 staff members and 2 residents were listed as having been COVID positive. Consultation of staff and medical records indicated that both residents had an admissions date prior to their date of contracting COVID-19. Staff members were also noted as having been employed by the facility during the date in which they contracted COVID-19.

During records review, it was observed that in 1 out of 5 files, resident MARs did not indicate administration of all medications indicated on medicine lists. During audit of medicine cabinet conducted on 8/26/2021, 1 out of 3 resident medication supplies were noted to have an empty supply of a prescribed PRN medication with no noted order for resupply. Review of resident records indicate that there was no discontinuation order noted for this medication.

The Department has conducted an investigation of the above allegations. Based on records reviewed, and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegations to be SUBSTANTIATED. Deficiencies are being cited. See LIC 9099-D. Exit interview conducted with Administrator Erin Wiley. A copy of this report, along with the facility's appeals rights were provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 26-AS-20210604091710
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/19/2021
Section Cited
CCR
87465(c)(3)
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87465 - Incidental Medical and Dental Care - (c) ...staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met... (3) A record of each dose is maintained in the resident's record. This requirement was not met as evidenced by:
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Licensee to submit written plan of staff training on recording administration of medication to CCLD by POC due date.
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Based on records received by CCLD, the facility did not maintain a record of each dose of medications listed on resident's medication list. This posed a potential risk to the health and safety of residents in care.
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Type B
11/19/2021
Section Cited
CCR
87465(c)(2)
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87465 - Incidental Medical and Dental care (c) ...staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met... (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by:
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Licensee to submit staff training and medical plan on meeting resident hygene needs to CCL by POC due date.
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Based on records reviewed and interviews conducted, R1 has a medical shamppo that the doctor order to use 3x per week, however, as per interviews staff was only providing R1 the special shampoo once or twice per week. Additionally, facility failed to refill one resident's medication with no discontinuation order. This posed a potential risk to the health and safety of residents 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: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 26-AS-20210604091710
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/13/2021
Section Cited
CCR
87211(a)(2)
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87211 - Reporting Requirements - (a) Each licensee shall furnish... reports as the Department may require, including.. (2) Occurrences, such as epidemic outbreaks... shall be reported within 24 hours. This requirement was not met as evidenced by:
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Licensee to submit written plan for reporting COVID outbreaks among staff or residents within 24 hours of contraction to CCLD by POC due date.
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Based on staff interviews and records received by CCLD, the facility did not submit a written report to CCLD within 24 hours of COVID-19 positive diagnoses within the facility. This posed an immediate risk to the health and safety of residents in care.
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Type A
11/13/2021
Section Cited
CCR
87468.1(a)(3)
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87468.1 - Personal Rights of Residents in All Facilities - (a) Residents... shall have all of the following personal rights... (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature... This requirement was not met as evidenced by:
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Licensee to submit written plan of action on staff training on resident rights as well as the safe transfer and redirection of residents to CCLD by POC due date.
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Based on staff, resident, and visitor interviews, facility staff assisted residents in manner that caused unnecessary discomfort and pain. This posed an immediate risk to the health and safety of residents 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: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
06/04/2021 and conducted by Evaluator Ryker Heberle
COMPLAINT CONTROL NUMBER: 26-AS-20210604091710

FACILITY NAME:PARADISE VILLAFACILITY NUMBER:
445202559
ADMINISTRATOR:ERIN ROSE WILEYFACILITY TYPE:
740
ADDRESS:2177 17TH AVENUETELEPHONE:
(831) 475-1380
CITY:SANTA CRUZSTATE: CAZIP CODE:
95062
CAPACITY:58CENSUS: DATE:
11/12/2021
UNANNOUNCEDTIME BEGAN:
02:12 PM
MET WITH:TIME COMPLETED:
05:11 PM
ALLEGATION(S):
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Food is not of nutritious quality
Resident sustained fall while under care of facility
Facility is not following visitation guidelines
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ryker Heberle conducted an unannounced complaint visit and met with Administrator, Erin Wiley, to deliver investigation findings.

On June 4th, 2021, the Department received the above allegations against the facility and conducted an initial complaint investigation visit on June 14th, 2021 to tour the facility, interview staff and residents, and request facility records.

During interviews with residents at the facility, 8 out of 8 residents interviewed stated that they believed that the food served at the facility was of nutritious quality. During inspection of the facility, LPA observed food being prepared to be served to residents for lunch, LPA observed food to contain all of the basic food groups.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 26-AS-20210604091710
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: 11/12/2021
NARRATIVE
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LPA observed that food being served to residents was not what was slated on the menu for that day. LPA interviewed facility staff in regards to why the food did not match the menu, interviewed staff member stated that the facility will occasionally swap menu items based on what he has available in the kitchen.

During interviews with family members visiting the facility, 4 out of 4 family members stated that they have not been denied entry into the facility. 3 out of 3 medical professionals visiting the facility stated that they had never been denied entry into the facility. LPA reviewed facility COVID visitation policy, which was noted to be in compliance with department guidelines.

LPA reviewed facility incident reports from January 2020 to present. All incident reports indicating falls were noted to have been reported within reporting guidelines. 0 out of 5 resident files reviewed during the course of the investigation indicated that residents at the facility had sustained a fall that warranted reporting to CCLD. In interviews with facility residents, 0 out of 9 residents indicated that they had fallen recently at the facility. 0 out of 6 staff interviewed indicated that they were aware of any recent falls at the facility that had gone unreported.

This Department has investigated the above allegation. Based on interviews, observations, and records review, the Department found that the above allegation is UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegation did or did not occur.

This report was reviewed with Administrator and a copy of this report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 6