445202559-8-16-2024-26-AS-KHOS-D8JNKX-20240827103240

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445202559
Report Date: 08/16/2024
Date Signed: 08/16/2024 04:50:33 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
01/06/2022 and conducted by Evaluator Grace Donato

COMPLAINT CONTROL NUMBER: 26-AS-20220106154559

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:	08/16/2024
		UNANNOUNCED	TIME BEGAN:	03:45 PM
MET WITH:	Lusanta Kaiyom & Saaj Kaiyom		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility did not provide responsible party with a copy of resident's Admissions Agreement
Resident not provided a 60 day written notice of rate increase

INVESTIGATION FINDINGS:

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

On 8/16/2024, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Licensees Lusanta & Saaj Kaiyom and explained the purpose of today's visit.

Regarding the allegation of Resident (R1) not provided a 60-day written notice of rate increase and facility did not provide responsible party with a copy of resident's Admissions Agreement. Reporting party (RP) states that after the resident's rate was increased, staff did not provide RP with a modified Admissions Agreement. RP also stated that the Administrator (ADM) says the rate increase is due to R1 “needing more attention" and also because "R1 needs hospice services." However, the resident's physician stated that the R1 doesn't need hospice services.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024

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 2

Control Number 26-AS-20220106154559

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: 08/16/2024

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

Based on records review, RP signed the original admissions agreement. The copy provided by the facility was dated on 11/25/2019. There is also a needs and services plan signed by the licensee & resident representative on 9/23/21.

Based on the information available, LPA was unable to prove whether ADM provided an 60-day letter to the responsible party for the rate increases.

Based on interviews & records review, the department has determined that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Report is reviewed and copy is provided.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2