445202559-11-12-2021-26-AS-KHOS-C9GSF2-20211207124938

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445202559
Report Date: 11/12/2021
Date Signed: 11/12/2021 05:08:45 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
05/18/2021 and conducted by Evaluator Ryker Heberle

COMPLAINT CONTROL NUMBER: 26-AS-20210518140650

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: 30	DATE:	11/12/2021
		UNANNOUNCED	TIME BEGAN:	02:12 PM
MET WITH:	Erin Wiley		TIME COMPLETED:	05:08 PM

ALLEGATION(S):

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Staff is not meeting the needs of the resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ryker Heberle conducted an unannoucned complaint visit and met with Administrator, Erin Wiley, to deliver investigation findings.

On May 18th, 2021, the Department received the above allegation against the facility and conducted an initial complaint investigation tele-visit on May 27th, 2021 to conduct a tour of the facility, interview administrator and request facility records.

From May 27th, 2021 through, July 29th, 2021, LPA conducted staff and resident interviews. LPA interviewed 8 residents. Of the 8 residents, 6 out of 8 felt that their needs were being met by the facility, while 1 stated that they were not, and 1 was unable to answer the question.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 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)

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Control Number 26-AS-20210518140650

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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During interview with 1 resident regarding how their needs were not being met at the facility (R4), LPA asked R4 whether or not facility staff was quick to respond to their needs. R4 indicated that staff never arrives when he/she calls for them. An additional resident, R3, stated while initially stating that their needs are met by the facility, stated that it often takes staff an hour or longer to arrive when he/she presses his/her pendant. Additional resident that stated that they receive one shower or sponge bath a week and were prefer to receive more.

LPA interviewed 11 staff members. Of the staff members interviewed 11 out of 11 stated that they believed that the facility was understaffed. When asked about whether or not they believed they were able to meet all the residents needs during the course of their shift. 11 out of 11 staff indicated that they were able to complete all of their tasks, however 8 out of 11 stated that they had felt that other shifts were unable to complete all of their necessary tasks in a given day. Review of staff scheduling indicated multiple days where there was only 1 caregiver assigned for both evening and night shift.

Facility had completed individual program plans and appraisal/needs and services plan to address individual residents’ needs and behavior. Based on record review, R3’s most recent appraisal/needs and services plan indicated that R3 was being monitored continuously and had been receiving additional care from an outside agency regularly. ANS showed that the facility addressed R3’s physical and mental condition by monitoring R3’s diet, physical appearance, activity, behavior, etc. Review of wound care notes indicated that R3 has been discovered in soiled sheets and clothing numerous times by home health nurses.

The Department has conducted an investigation of the above allegations. Based on LPAs’ observations, 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 Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 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 3

Control Number 26-AS-20210518140650

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 87411(a)	1 2 3 4 5 6 7	87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee to submit written statement of staffing increases and staffing schedule action to CCLD by POC due date.
	8 9 10 11 12 13 14	Based on resident/staff interviews and records reviewed, facility does not have enough staff necessary to assist residents with care in a timely manner. This poses a potential risk to the health and safety of residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 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)

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