445202559-3-11-2022-26-AS-KHOS-CU3MKF-20230725094039

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445202559
Report Date: 03/10/2022
Date Signed: 03/11/2022 08:37:38 AM

Unsubstantiated

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
08/23/2021 and conducted by Evaluator Ryker Heberle

COMPLAINT CONTROL NUMBER: 26-AS-20210823121856

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:	03:57 PM
MET WITH:	Erin Wiley		TIME COMPLETED:	05:05 PM

ALLEGATION(S):

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Staff are not allowing visitors to see resident.

INVESTIGATION FINDINGS:

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

On August 20th, 2021, the Department received the above allegation against the facility and conducted an initial complaint investigation visit on August 26th, 2021 to conduct a tour of the facility, interview staff and residents, and request facility records.

During the course of the investigation LPA interviewed 5 family members of residents. 5 out of 5 family members stated that they had never been denied entry into the facility upon arrival.

Continued in 9099-C

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: 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)

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Control Number 26-AS-20210823121856

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

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During visits to the facility LPA interviewed facility staff and residents. Of the staff interviewed, 3 out of 3 stated that they had never heard of visitors not being allowed into the facility. Of residents interviewed, 5 out of 5 stated that they were not aware of any instance in which family members were not allowed to visit them.

1 out of 3 staff interviewed stated that the only instance in which visitation was denied to a visitor was when a resident's family member had arrived at the facility without giving the facility notice, after which they refused to provide proof of vaccination or a negative COVID test. Said visitor was also accompanied by an unidentified individual who refused to declare themselves or present proof of vaccination/negative test.

The Department has investigated the above allegation. Based on interviews conducted, 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: 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)

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