445202559-5-24-2022-26-AS-KHOS-CHJQX8-20220822123306

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445202559
Report Date: 05/24/2022
Date Signed: 05/24/2022 03:44:58 PM

Substantiated

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
12/13/2021 and conducted by Evaluator Ryker Heberle

COMPLAINT CONTROL NUMBER: 26-AS-20211213110705

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:	0	CENSUS: 21	DATE:	05/24/2022
		UNANNOUNCED	TIME BEGAN:	03:20 PM
MET WITH:	Christina Rivas		TIME COMPLETED:	03:50 PM

ALLEGATION(S):

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Facility staff failed to seek timely medical attention for resident.

INVESTIGATION FINDINGS:

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Licensing Program Analysts Ryker Heberle (LPA) and Mandeep Kaur conducted an unannounced visit to close a complaint investigation regarding the above allegation. LPA spoke with Administrator Christina Rivas (Admin), the currently administrator of the facility after change of ownership (new facility #445202851).

On 11/29/2021, a resident (R1) burned his/her thigh with hot coffee, R1 was sent to Dominican Hospital for evaluation. It was noted on R1's discharge paper work that he/she was to be sent to the Santa Clara Valley Medical Burn Unit (SCVM) "as soon as possible." R1 was taken to SCVM 9 days later.

In review of facility files, there was no written documentation for the delay in sending R1 to the burn unit.

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: 05/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022

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 3

Control Number 26-AS-20211213110705

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: 05/24/2022

NARRATIVE

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In interview with facility administrator Erin Wiley (FA) on 03/09/2022, Admin stated that R1 had a delay in being deployed to SCVM due to SCVM not having enough beds and due to troubles arranging transportation. According to FA, SCVM stated that R1's burns did not sound life threatening, so his/her appointment was set for 12/07/2021, which was later changed to 12/08/2021.

During the period between discharge from the hospital and admission to SCVM, R1's wounds were cleaned and redressed by facility staff numerous times per day. 2 out of 3 staff interviewed that assisted with wound care stated that R1's wounds worsened during the interim period due to R1 ripping of his/her bandages and picking at the wounds. Staff stated that they frequently changed R1's bandages, but the redressing was not officially documented.

Review of SCVM medical records note that while there were no foul odors or significant discharge from the burn, they questioned why it took so long for the facility to take R1 to the burn unit. In a follow up with Dominican Hospital Urgent care, it was clarified that R1 should have gone to SCVM the same day that he/she was discharged from the hospital.

The Department has conducted an investigation of the above allegations. Based on interviews and file review, the facility did not provide timely medical attention for R1 in response to the worsening of his/her burn wounds despite instruction from the hospital that treatment was needed as soon as possible. Therefore, the preponderance of evidence standard has been met, the Department has found the above allegation to be SUBSTANTIATED.

Deficiency is being cited. See LIC 9099-D. Exit interview conducted with current Administrator Christina Rivas. 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: 05/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20211213110705

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: 05/24/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/25/2022 Section Cited CCR 87465(a)(1)	1 2 3 4 5 6 7	87465(a)(1) - Incidental Medical and Dental Care - (a) A plan for incidental medical and dental care shall be developed by each facility... (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee to review Title 22 and receive training for how to assess residents to determine need for greater medical care by POC due date.
	8 9 10 11 12 13 14	Based on interviews and records review, the facility did not assist R1 with obtaining emergency medical assistance in response to worsening burn wounds. This posed an immediate 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: 05/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022

LIC9099 (FAS) - (06/04)

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