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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 445202559
Report Date: 10/18/2024
Date Signed: 10/28/2024 12:17:04 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
04/04/2022 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20220404154530
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:
10/18/2024
UNANNOUNCEDTIME BEGAN:
09:27 AM
MET WITH:Lusanta KaiyomTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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9
Resident left in soiled diapers
Resident not receiving showers per schedule
Resident clothes not changed
INVESTIGATION FINDINGS:
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13
*** This is an amended Report ***

On 10/28/24, 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 allegations of residents left in soiled diapers, resident not receiving showers per schedule, resident clothes not changed, Reporting Party (RP) stated that RP observed R1 to be in soiled diaper, or no diaper, and the same clothes for 1 week, no shower. RP observed other residents lying in bed when RP normally sees them engaged in activities or visiting in the Hub room first floor. These residents use wheelchairs and are unable to get out of bed on their own. Witness resident calling for help and no staff came. RP went and looked for staff.

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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)
Page: 1 of 3
Control Number 26-AS-20220404154530
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 three staff members. S1 mentioned that they always check the residents every 2 hours, or if they pass by the rooms, they just check on the residents if there is anything they need. Some residents are aggressive sometimes, so they wait and give them time if they refuse showers. They do ask them three times. With the change in clothes, they also ask them three times too, if they still don's say yes then staff will wait and find a time. 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, they check more frequently. S3 mentioned that they don’t force residents to take showers. They ask at least three times or just adjust the shower schedule. With all the activities of daily living, staff asks at least three times. If residents still say no, then we’ll reschedule and with the clothing we try to come back after a few hours. LPA was also able to interview 2 residents (R2 & R3). 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. R3 also stated that they (staff) always take care of R3 and has no issues. They always come when R3 needs help.

Based on interviews, 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 allegations are UNSUBSTANTIATED.

Report is reviewed and copy is provided.
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)
Page: 2 of 3
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
04/04/2022 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20220404154530

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:
10/18/2024
UNANNOUNCEDTIME BEGAN:
09:27 AM
MET WITH:Lusanta KaiyomTIME COMPLETED:
02:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
No qualified administrator on site
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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 no qualified administrator on site, Reporting Party (RP) stated that there is no Qualified Administrator on Duty at the facility. No one has been identified as the administrator.

Based on records review, the facility has a qualified administrator namely the Licensee. Administrator Certificate provided has qualification date of 8/9/2021 to 8/8/2023.

Based on records review, the department has determined that that the allegation was false, could not have happened and/or is without a reasonable basis, therefore the allegation is UNFOUNDED.

Report is reviewed and copy is provided.
Unfounded
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)
Page: 3 of 3