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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 05:15:02 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
06/23/2021 and conducted by Evaluator Ryker Heberle
COMPLAINT CONTROL NUMBER: 26-AS-20210623111914
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:
05:14 PM
ALLEGATION(S):
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Resident was not given access to emergency call pendant
Resident was left in bed with soiled sheets
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 June 23rd, 2021, the Department received the above allegation against the facility and conducted an initial complaint investigation visit on June 29th, 2021 to tour the facility, interview staff and residents, and request facility records.

On July 29th 2021, LPA overheard a resident shouting for help. LPA entered the resident's room and asked resident if he/she required assistance. LPA asked resident to press his/her pendant and await staff. Resident pressed his/her pendant and LPA waited in the room with the resident for staff to arrive. After waiting approximately 15 minutes, LPA sought staff assistance.
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 5
Control Number 26-AS-20210623111914
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 and Administrator reentered the room and observed the pendant. Upon inspection, the pendant was discovered to be missing batteries. Upon replacement of batteries, resident call pendant was again observed to not be functioning. Administrator then provided resident with replacement pendant, that LPA observed to operating properly

6 out of 11 staff members interviewed stated that they had arrived to discover residents left in soiled sheets or clothes upon beginning their shift, but were unable to determine how long residents had been left. 6 out of 11 staff interviewed indicated that the facility is short staffed. Sunday was indicated as a day that was particularly short staffed. Review of facility staffing schedule revealed that staffing schedule was inaccurate. Staff schedule included staff members that were no longer working at the facility and was missing staff that was currently working at the facility.

1 out of 3 family members interviewed stated that they had arrived to find their loved ones in soiled clothes or sheets. 9 residents were interviewed 2 out of 9 residents stated that the did not received help in a timely manner. When asked about how long it took for staff to arrive, 1 resident stated that staff often never arrives to assist him. 1 resident stated that it usually takes staff around an hour to arrive.

The Department has conducted an investigation of the above allegations. Based on LPAs’ observations, 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 5
Control Number 26-AS-20210623111914
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
87303(i)(1)(B)
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87303 Maintenance and Operation
(i) Facilities shall have signal systems which shall meet the following criteria: (1) ...shall have a signal system which shall... (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. This requirement was not met as evidenced by:
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Licensee to submit written plan of new alert system currently being installed into facility to CCLD by POC due date.
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Based on observation, the facility did not provide a functioning signal device to a resident in care. This posed an immediate risk to the health and safety of residents in care.
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Type B
11/19/2021
Section Cited
CCR
87464(f)(4)
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87464 - Basic Services - (f) Basic services shall at a minimum include... (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications... This requirement was not met as evidenced by:
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Licensee to submit staffing plan in meeting residents basic needs to CCL by POC due date.
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Based on interviews and records reviewed, residents had been observed by staff and visitors to be in wet/soiled sheets or clothes, which poses an immediate health risk to 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 5
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
06/23/2021 and conducted by Evaluator Ryker Heberle
COMPLAINT CONTROL NUMBER: 26-AS-20210623111914

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:
05:14 PM
ALLEGATION(S):
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Fire Exit was blocked
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 June 23rd, 2021, the Department received the above allegation against the facility and conducted an initial complaint investigation visit on June 29th, 2021 to tour the facility, interview staff and residents, and request facility records.

During inspection on June 29th, LPA observed a bed tipped on it’s side near the facility back gate, which operates as emergency exit. Facility fire exit was capable of completely opening, and the pathway was observed to be easily traversable. No other fire exits noted to be obstructed.
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: 4 of 5
Control Number 26-AS-20210623111914
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 review of photo documentation submitted to licensing, LPA determined that the position of the bed did not match the position of the bed in the photo. Additionally, photo documentation did not include the presence of an alternate accessible walkway that leads to the fire exit. 2 out of 2 staff interviewed stated that the bed had not been obstructing the exit and that they were in the process of scheduling movers to take it to the dump. Bed was observed to no longer be on the premises during additional complaint investigation on 8/26/2021.

The Department has investigated the above allegation. Based on LPA observation, interviews, 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 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: 5 of 5