445202559-7-6-2023-26-AS-KHOS-CU3JPZ-20230725071421

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445202559
Report Date: 07/06/2023
Date Signed: 07/06/2023 02:52:15 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 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
09/22/2020 and conducted by Evaluator Ryker Heberle

COMPLAINT CONTROL NUMBER: 26-AS-20200922111219

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: 0	DATE:	07/06/2023
		UNANNOUNCED	TIME BEGAN:	12:32 PM
MET WITH:	Lusanta Kaiyom		TIME COMPLETED:	02:55 PM

ALLEGATION(S):

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Staff failed to prevent resident from wandering from the facility while in care
Staff failed to follow admission agreement

INVESTIGATION FINDINGS:

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Licensing Program Analyst Ryker Heberle (LPA) arrived unannounced at the facility to conclude a complaint investigation regarding the above allegations. LPA met with facility Administrator Sajj Kaiyom (Admin).

During initial complaint investigation conducted LPAs interviewed the then facility administrator Erin Wiley (S1), S1 stated that there had been an incident at the facility in which a resident (R1) was in the process of being admitted into the facility. Upon entrance into the facility S1 claims that R1 assaulted staff members, and exited the facility. S1 stated that R1 was followed by staff. R1's family member (W1) was still in the facility parking lot, and redirected R1 back into their car. S1 stated that admission process was not completed. S1 was unable to provide a completed admissions agreement or need and services plan to the department.

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: 07/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

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-20200922111219

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: PARADISE VILLA	FACILITY NUMBER: 445202559
	VISIT DATE: 07/06/2023

NARRATIVE

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In an email from the reporting party, it was indicated that the original paperwork for R1's plan of care was filled out 2 days before R1's move in date. Initial complaint indicated that after being dropped off, R1 "escaped down the stairs and out the front door," report states that staff assisted W1 in getting R1 into their car, and both left the facility. LPA attempted to contact the reporting party via the phone number left with the department, but the number redirected to an unrelated party.

S1 indicated that R1 had since been refunded their $2100 initial rent on 09/25/2020. Review of facility emails indicate that email correspondence did occur between R1's family and the facility, but the emails appeared to have been deleted. Emails that still existed confirmed R1's elopement from the facility, but do not elaborate on the details of the incident. During inspection conducted on 07/06/2023, LPA was unable to obtain documents reflective of R1's care nor obtain emails confirming admission of R1 nor refund to R1's family, due to them no longer existing at the facility.

Based on information from interviews conducted with staff and records reviewed, although the allegations listed above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur; therefore, the allegation is UNSUBSTANTIATED.

No deficiencies cited under Title 22 during this visit. Report was reviewed with and signed by Administrator Lusanta Kaiyom and a copy was provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

LIC9099 (FAS) - (06/04)

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