445202559-6-4-2021-26-AS-KHOS-C69J4C-20210826064256

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445202559
Report Date: 06/04/2021
Date Signed: 06/04/2021 04:10:52 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
02/10/2021 and conducted by Evaluator Ryker Heberle

COMPLAINT CONTROL NUMBER: 26-AS-20210210080221

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:	58	CENSUS: 27	DATE:	06/04/2021
		UNANNOUNCED	TIME BEGAN:	04:00 PM
MET WITH:	Erin Wiley		TIME COMPLETED:	04:09 PM

ALLEGATION(S):

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Resident sustained fracture while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPAs) Ryker Heberle and Joanne Roadilla conducted an unannounced visit to deliver the complaint investigation finding. LPAs met with Erin Wiley, Administrator.

Department opened a complaint on 02/11/2021 regarding the above allegation. During the investigaiton, the department interviewed: 1 family member of resident, 3 facility residents, 3 facility staff and 1 medical professional and reviewed the file of 1 resident.

Continued on 9099-C

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2021

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-20210210080221

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: PARADISE VILLA	FACILITY NUMBER: 445202559
	VISIT DATE: 06/04/2021

NARRATIVE

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The Department reviewed resident's (R1) medical records on 2/22/2021. R1 was taken to the hospital on 11/5/2020 due to having something heavy thrown at R1 with no injuries. Medical records indicate that R1 had a closed nondisplaced fracture on right femur that had existed since 5/4/2020. R1 was placed in the facility in July 2020. Medical staff noted tenderness on R1's left hip, but right hip prosthesis appeared unchanged with no additional injuries.

R1's medical record indicated that on 10/8/2020, R1 was taken to the hospital where it was noted that R1's dementia had been worsening. R1 continues having hallucinations, seeing things, and having confabulating stories. During interview with R1 that took place on 2/22/2021, R1 reiterated that another resident had thrown a chair at R1. R1 was unable to identify which resident threw the chair, nor could R1 identify any witnesses.

The Department interviewed 2 facility residents on 2/25/2021. Neither of the two residents interviewed recalled an incident where a heavy object was thrown at R1. Neither resident could recall being told by R1 that R1 had had a heavy object thrown at R1. One resident (R2) interviewed indicated that R1's dementia was worsening and that R1 would "lie about random stuff."

3 staff interviewed denied R1 suffered any injuries while in care & that R1 was able to walk using the walker the entire time while in the facility. All staff interviewed also stated that R1 believed that others would kick R1 when nobody was around R1. The medical doctor interviewed confirmed that the fracture noted during the 11/5/2020 doctor's visit was the same fracture R1 had in May 2020. There were no new fractures.

The Department has investigated the above allegation. Based on interviews conducted and document review, the Department found the above allegation to be UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

Report reviewed with Erin Wiley, Administrator, and a copy of this report provided for signature.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2021

LIC9099 (FAS) - (06/04)

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