445202559-10-18-2024-26-AS-KHOS-DABM68-20241023091930

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445202559
Report Date: 10/18/2024
Date Signed: 10/18/2024 02:13:52 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
02/07/2022 and conducted by Evaluator Grace Donato

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20220207082111

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:	10/18/2024
		UNANNOUNCED	TIME BEGAN:	09:27 AM
MET WITH:	Lusanta Kaiyom		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Residents in care are being neglected
Staff left resident unattended for extended period of time
Staff handled resident in a rough manner
Staff failed to administer resident’s medication in a timely manner
Staff failed to provide adequate food service

INVESTIGATION FINDINGS:

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On 10/18/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Licensee, Lusanta Kaiyom and explained the purpose of today's visit.

Regarding the allegation of Residents in care are being neglected and staff left resident unattended for extended period of time, reporting party (RP) stated that the facility staff are neglecting the residents in care and failing to meet their needs. Several residents told RP that they had not been changed and were left unattended in soiled wet clothing and wet linens for extended periods of time. The residents reported that several times they called the staff by pressing their call assistance button, but no one responded.

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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024

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-20220207082111

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: 10/18/2024

NARRATIVE

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LPA was able to interview staff members (AD1, S1 & S2). AD1 mentioned that during NOC shift, residents are checked at least every 3 hours or as needed. S1 mentioned that they always check the residents every 2 hours, or if they pass by the rooms, they just check on them if there is anything they need. S2 also mentioned that they go around and check the residents if they need anything. Usually, every 2 hours and if some of them calls with the pendant. If staff are aware of their incontinence, staff will also check more frequently. LPA was also able to interview 3 residents. R1 & R2 Both mentioned that they are well taken care of in the facility. R2 mentioned that staff is always there when R2 needs anything. When call button is pressed staff comes, and they assist in anything needed. Another resident, R3 also stated that they (staff) always take care of R3 and has no issues. They always come when R3 needs help.

Regarding the allegation of staff handled resident in a rough manner, RP stated that a few weeks ago a resident (R1) pressed the call assistance button, and a staff member (name unknown) came and grabbed R1 by the neck and removed the call assistance button and told R1 that he/she was pressing the call assistance button too many times (no injuries reported).

LPA spoke with R1 and doesn’t remember an instance of neck grabbing. R1 stated that the call button is always with him/her and knows how to operate it.

Regarding the allegation that staff failed to administer resident’s medication in a timely manner. RP stated that RP stated that another resident (R4) reported that several times the staff failed to administer his/her medication. On an unknown date R4 was shaking because the staff did not administer his/her medication.

LPA interviewed R4 and he/she stated that the medications are with him/her. It's locked. Staff reminds R4 when he/she needs to take it. Doesn't remember if staff gave it late when the facility was still handling the medication.

Based on records review, Medication Administration Records (MAR) shows that the medication was given and initialed by staff.

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SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20220207082111

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: 10/18/2024

NARRATIVE

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Regarding the allegation of staff failed to provide adequate food service, RP stated that another resident (R5) who reported that several times was not given his/her dinner.

LPA interviewed AD1 and it was mentioned that the residents who are not able to go to the dining room are provided food in their respective rooms. If they don’t want to eat a lot, staff will ask several times to try and feed but will not force residents to eat if they don’t want too.

Based on records review, AD1 provided daily intake logs and it showed that residents are provided food and its noted how much food intake each resident had.

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

Report is reviewed and copy is provided.

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SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024

LIC9099 (FAS) - (06/04)

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