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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 445202559
Report Date: 08/16/2024
Date Signed: 08/16/2024 04:47:51 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
01/18/2022 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20220118115318
FACILITY NAME:PARADISE VILLAFACILITY NUMBER:
445202559
ADMINISTRATOR:ERIN ROSE WILEYFACILITY TYPE:
740
ADDRESS:2177 17TH AVENUETELEPHONE:
(831) 475-1380
CITY:SANTA CRUZSTATE: CAZIP CODE:
95062
CAPACITY:0CENSUS: 0DATE:
08/16/2024
UNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Lusanta Kaiyom & Saaj KaiyomTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Facility interfered with resident's mail
INVESTIGATION FINDINGS:
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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 facility interfered with resident's mail, Reporting Party (RP) states that the facility interfered with the Resident (R1).

According to the RP, on 1/13/2022, R1 passed away. RP states that on 1/14/2022, the resident's POA asked RP to accompany him/her to the facility to collect R1s belongings. RP states that while the POA was gathering R1s belongings, Administrator (ADM) gave the POA multiple letters that R1 had given the to mail. RP states that when R1 gave the ADM the letters to mail, instead of the ADM mailing the letters, ADM retained the letters, and also opened and read some. RP states that many of the letters given to the POA had been opened and read by the ADM.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: 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-20220118115318
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
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LPA is not able to get hold of the ADM working during this time, therefore is not able to get the side of the alleged party.

Based on interviews, 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 JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: 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