445202559-10-3-2024-26-AS-KHOS-DABMU9-20241023095446

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445202559
Report Date: 10/03/2024
Date Signed: 10/03/2024 02:02:02 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
04/29/2022 and conducted by Evaluator Grace Donato

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20220429130343

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:	10/03/2024
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Lusanta & Saaj Kaiyom		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff handled resident in a rough manner.

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 allegation of Staff handled resident in a rough manner, Reporting Party (RP) stated that he/she has witnessed a staff member (S1) handle the residents in a rough manner. RP reported that a paralyzed resident (RP unable to recall resident's name) was very upset because S1 threw him/her off the bed. RP was made aware of the incident because the resident was yelling when he/she arrived for his/her shift.

LPA interviewed RP and has provided the same information given to the original complaint filed. However, LPA is not able to get any information from S1 as there is no available contact number. LPA also interviewed the Licensee, and they were not aware of the incident that happened during this time.

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.

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: 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)

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