445202559-3-11-2022-26-AS-KHOS-CU3MWL-20230725095830

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445202559
Report Date: 03/10/2022
Date Signed: 03/11/2022 08:56:32 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
12/22/2021 and conducted by Evaluator Ryker Heberle

COMPLAINT CONTROL NUMBER: 26-AS-20211222141609

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:	04:08 PM
MET WITH:	Erin Wiley		TIME COMPLETED:	05:05 PM

ALLEGATION(S):

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Staff interfered with the work of duly authorized representative

INVESTIGATION FINDINGS:

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

On December 22nd, 2021, the Department received the above allegation against the facility and conducted an initial complaint investigation visit on December 29th, 2021 to conduct a tour of the facility, interview administrator and request facility records.

In an interview with an individual from an outside agency (W1), W1 told LPA that they were unable to complete duties in assisting a facility resident (R1) due to Admin indicating to W1 that R1 was conserved. In order to complete his/her duties, W1 needed to get permission from R1's conservator. When W1 reached out to the alleged conservator (RP), RP told W1 that R1 had never been conserved

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)

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Control Number 26-AS-20211222141609

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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Upon arriving at the facility, LPA interviewed Admin. LPA asked how many residents at the facility were currently conserved. Admin told LPA that they had one conserved resident in the facility. LPA asked for the conserved resident's (R1) documentation and contact information regarding conservatorship. After request of conservatorship documents, Admin was unable to locate documentation or records of conservatorship. In review of R1's file, LPA did not observe any documents indicating conservatorship. Admin later concluded that R1 was not conserved as originally thought.

LPA interviewed RP, RP indicated that R1 had never been conserved and that he/she was merely R1's power of attorney, RP stated that R1 did not need his/her permission to speak to individuals from outside agencies. Based on Admin's consistent assertions that R1 was conserved until documentation did not surface, and confirmation with R1's responsible person, it can be concluded that R1's mistaken conservatorship status lead to them not receiving services from W1 that they were entitled to.

The Department has conducted an investigation of the above allegations. Based on interviews and records review, 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 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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Control Number 26-AS-20211222141609

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 87405(h)(1)	1 2 3 4 5 6 7	87405 Administrator - Qualifications and Duties - (h) The administrator shall have the responsibility to: (1) Administer the facility in accordance with these regulations and established policy, program and budget. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrators will review title 22 and will submit a written statement that they understand the regulations, including personal rights of residents and staff, medication management, maintenance and operation, and basic services by POC due date.
	8 9 10 11 12 13 14	Based on LPA observation, interviews, document review, and history of prior substantiated complaints and deficiencies, the facility is not being administrated in compliance with Title 22 regulations. This poses an immediate risk to the health and safety of residents in care.	8 9 10 11 12 13 14	Department to determine necessity of office visit for non-compliance conference.
Type B 03/17/2022 Section Cited CCR 87468.1(a)(11)	1 2 3 4 5 6 7	87468.1 - Personal Rights of Residents in All Facilities - (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights... (11)To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee to review resident files and conservatorship policies and provide proof of correction by POC due date
	8 9 10 11 12 13 14	Based on interviews, and document review, the facility mistakenly identified a resident as conserved, preventing outside agency from completing provision of service. This poses a potential risk to the health and safety of residents in care.	8 9 10 11 12 13 14

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)

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