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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 445202559
Report Date: 10/03/2024
Date Signed: 10/03/2024 02:00:51 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
08/20/2021 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20210820122915
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:
10/03/2024
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Lusanta & Saaj KaiyomTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Staff not administering medication to resident as required.
Staff not competent to meet resident's needs
Refund not provided upon resident’s death
Facility made false statements regarding resident's care
INVESTIGATION FINDINGS:
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On 10/3/24, 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 allegations of staff not administering medication to resident as required, staff not competent to meet resident's needs and facility made false statements regarding resident's care, RP stated that on 08/05/21 or 08/06/21, R1 was complaining about being in pain and can administer morphine as needed. RP stated he/she informed Administrator (A1) to administer morphine, but A1 refused. RP stated on 08/09/21, RP visited R1 around 11:00am and observed there was no bedding on R1s bed. RP stated when he/she looked in the corner, RP saw R1 sitting in a chair looking as if R1 was sliding off. RP stated he/she requested for staff (name unknown) to assist R1 back on her bed. RP stated a supervisor (S1) came into the room and informed RP that staff (name unknown) probably tried feeding R1. RP stated S1 contacted A1, A1 stated it was hospice orders to have R1 sit in a chair. RP stated he/she contacted hospice and spoke with a staff member (name unknown), the staff member stated there is no order on record for R1 to sit in a chair.
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: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
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-20210820122915
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: 10/03/2024
NARRATIVE
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LPA Donato tried to reach out to the staff members (A1 & S1) but is not able to reach anyone, to get their side of the story. LPA also called the hospice agency based on the records provided by the facility but the hospice confirmed that there was no agreement with them with R1.

Regarding the allegation of refund not provided upon resident’s death, RP stated he/she spoke with A1 regarding a refund. Per RP, A1 stated he/she would provide RP with a refund.

LPA tried to reach RP, A1 and the former Licensee to confirm if a refund was issued but all parties were not available. LPA left messages but no call backs.

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 allegation is UNSUBSTANTIATED.

Report is reviewed and a copy is provided.

SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2