445202559-3-11-2022-26-AS-KHOS-CU3MSL-20230725095207

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445202559
Report Date: 03/10/2022
Date Signed: 03/11/2022 08:45:42 AM

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
11/12/2021 and conducted by Evaluator Ryker Heberle

COMPLAINT CONTROL NUMBER: 26-AS-20211112153031

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: 26	DATE:	03/10/2022
		UNANNOUNCED	TIME BEGAN:	03:59 PM
MET WITH:	Erin Wiley		TIME COMPLETED:	05:05 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff do not treat resident(s) with dignity.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

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

On November 12th, 2021, the Department received the above allegation against the facility and conducted an initial complaint investigation visit on November 19th, 2021 to tour the facility, interview staff and residents, and request facility records.

During the inspection on November 19th 2021, LPA inspected room 10, while attempting to inspect restroom, LPA observed the restroom door to be barricaded from the inside. LPA was able to remove the blockade and enter the restroom. Upon entering the restroom, LPA observed a toilet with no water in the tank or bowl, that had odorless, grey particulate matter coating the inside of the bowl.

Continued in 9099-C

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: 03/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022

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-20211112153031

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: 03/10/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA interviewed facility residents. 1 out of 3 residents interviewed stated that they had been unable to use the restroom in their room for over a month. 1 out of 3 residents stated that they had to use the public restroom for a month due to their toilet being broken. Resident that had to use the public restroom (R1) stated that staff had blamed and scolded him/her for breaking the toilet, and that was why he/she had to use the public restroom. Admin stated that staff had not scolded residents for breaking toilets, but had to remind them multiple times not to flush wipes down the toilet.

In an interview with a witness (W1), W1 indicated that they had observed the toilet in a condition of disrepair similar to those observed by LPA during visit on November 4th, including grey particulate matter on the toilet and the bathroom being blockaded.

During interview with facility staff members, 2 out of 2 staff indicated that the condition of the toilet must have been recent, and were unable to identify the grey particulate matter inside the toilet. Facility administrator called staff to fix the toilet but indicated to LPA that the repairs required special tools beyond the scope of what the facility had available.

Review of facility plumbing invoices indicate that the toilet was last serviced on September 15, 2021. Most recent invoice indicated that the toilet had been broken due to the flushing of "wipes" down the toilet. On November 22nd, 2021, Admin sent LPA an additional plumbing invoice indicating that repairs had been completed.

The Department has conducted an investigation of the above allegation. Based on LPA's observations, interviews conducted, and records reviewed, the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED. Deficiency 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: 03/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20211112153031

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: 03/10/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/11/2022 Section Cited CCR 87468.1(a)(3)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities - (a)(3)...to be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as... interfering with daily living functions such as... elimination. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Toilet has been fixed prior to this visit. POC is cleared
	8 9 10 11 12 13 14	Based on LPA observation, interviews, and document review, the facility did not repair a resident's toilet in a timely manner, prohibiting resident from fulfilling daily living functions, resident also felt humiliated. 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: 03/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3