445202559-11-12-2021-26-AS-KHOS-CA4QFS-20211227110825

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445202559
Report Date: 11/12/2021
Date Signed: 11/12/2021 05:18:35 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
07/20/2021 and conducted by Evaluator Ryker Heberle

COMPLAINT CONTROL NUMBER: 26-AS-20210720162346

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:	05:18 PM

ALLEGATION(S):

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Resident medication is being stolen

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 July 20th, 2021, the Department received the above allegation against the facility and conducted an initial complaint investigation visit on July 29th, 2021 to conduct a tour of the facility, interview staff and residents, and request facility records.

Between July 20th 2021 and July 29th 2021, LPA interviewed 6 staff members in regards to the facility medication policy. 4 out of 6 staff members stated that they had never heard of medication going missing from the facility, while 2 out of 6 stated that medication went missing.

Unsubstantiated

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-20210720162346

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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Between July 20th and July 29th, LPA interviewed 4 residents, 4 out of 4 residents interviewed indicated that they had not been aware of medication going missing. 4 out of 4 residents indicated that they received their medication regularly and had not noted any missing medication.

On July 29th 2021, LPA reviewed facility medication destruction policy and medication destruction records for 3 residents. 3 out of 3 resident medication destruction records were noted to be complete with signatures from both designated representatives and witness adult non-clients.

The Department has investigated the above allegation. Based on interviews conducted and records reviewed, 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 Erin Wiley and a copy of the report was 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)

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