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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 445202559
Report Date: 07/29/2021
Date Signed: 07/29/2021 01:42:26 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
09/29/2020 and conducted by Evaluator Ryker Heberle
COMPLAINT CONTROL NUMBER: 26-AS-20200929134214
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:58CENSUS: 20DATE:
07/29/2021
UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Erin WileyTIME COMPLETED:
01:43 PM
ALLEGATION(S):
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1. Lack of care and supervision resulting in resident sustaining injuries while in care.
2. Facility falsified records and did not report unusual incident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ryker Heberle conducted a complaint visit today to deliver investigation findings. LPA met with Administrator Erin Wiley.

On 09/29/2020, the Department received a complaint against the facility alleging lack of care and supervision for resident (R1) resulting in R1 falling multiple times and sustaining injuries from the falls. Additionally, the facility was alleged to falsify residents' records and not report serious incidents to the licensing agency.

On 10/02/2020, the Department initiated investigation of the above allegations. The investigation revealed that R1 was a resident of the facility since 12/29/2018. R1's Appraisal/Needs and Services Plan (ANS) dated 01/06/2020, indicated that R1 has a history of falls and wandering/eloping.

Continued, see LIC 9099-C, page 2 of 3.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021
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 9
Control Number 26-AS-20200929134214
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: 07/29/2021
NARRATIVE
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Review of R1's hospital records showed that R1 was taken to the hospital on 08/01/2019, 10/12/2019, 11/06/2019, 07/04/2020, 11/11/2020, 12/16/2020, 12/19/2020, and 12/28/2020 due to injuries from unwitnessed falls, including lacerations to the top of head and scalp, mild contusion/abrasion to the back of head, and finger fracture.

A review of incident reports received by Community Care Licensing Division (CCLD) was conducted and revealed that CCLD did not receive a report from the facility within 7 days of the 11/06/2019 and 12/16/2020 incidents.

Interviews of facility staff were conducted. All staff who were interviewed stated that R1 had fallen multiple times while in care. 2 out of 4 staff stated they have not received proper training to address R1's behaviors. 2 out of 4 staff stated they believe R1 needs a higher level of care than what facility staff can provide which results in R1's frequent falls with injuries.

Facility records for R1, including Appraisal/Needs and Services Plan (ANS), Physician's Report, Admission Agreement, Medication Administration Records (MAR), and caregiver notes were obtained and reviewed. The facility provided copies of R1's ANS dated 01/06/2020 and 11/04/2020. Both ANS do not identify a plan for the facility to address R1's fall history and wandering/eloping behavior. R1's ANS dated 01/06/2020 contained a signature of R1's responsible party (RP) that did not match RP's signature on other documents. RP was interviewed, asked to verify the signature, and confirmed the signature was not RP's.

Review of R1's MAR was conducted. MARs provided by the facility showed medication was given to R1 without incident for the months of March and April 2020. A document dated 04/06/2020 sent by the facility to R1's physician stated R1 refused nighttime medication 2 nights in a row. MARs reviewed showed complete signatures on each day of the month indicating the medication was administered daily.

All staff who were interviewed stated that staff (S3) is responsible for completing and submitting incident reports to CCLD. On 10/28/2020, during interview, S3 admitted that no incident report was submitted to CCLD for R1's 11/06/2019 fall incident with injuries.

Continued, see LIC 9099-C, page 3 of 3.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021
LIC9099 (FAS) - (06/04)
Page: 9 of 9
Control Number 26-AS-20200929134214
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: 07/29/2021
NARRATIVE
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The Department has conducted an investigation of the above allegations. Based on LPAs’ observations, records reviewed, and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegations to be SUBSTANTIATED.

Deficiencies are being cited. See LIC 9099-D. Exit interview conducted with Administrator Erin Wiley. A copy of this report along with the facility's appeals rights were provided during visit.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 9
Control Number 26-AS-20200929134214
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/30/2021
Section Cited
CCR
87705(c)(5)(A)
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87705 CARE OF PERSONS WITH DEMENTIA (c)(5)(A) When any medical assessment, ...or observation indicates that the resident’s dementia care needs have changed, corresponding changes shall be made in the care and supervision provided to that resident.
This requirement was not met as evidenced by:
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Licensee to audit all residents' ANS who have dementia care need changes to ensure corresponding changes are made in the care and supervision plan to meet residents' needs. A copy of facility's audit list shall be submitted to CCLD by POC due date.
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Based on staff interviews & records review, staff has knowledge of R1's fall history yet failed to make corresponding changes to include fall prevention in R1's ANS to meet R1's care & supervision needs, resulting in R1 sustaining mutiple falls with injuries. This posed an immediate health & safety risk to R1.
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Type B
08/06/2021
Section Cited
CCR
87211(a)(1)(B)
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87211 REPORTING REQUIREMENTS (a)(1) A written report shall be submitted to the licensing agency...within 7days of the occurrence of...(B)Any serious injury...occurring while the resident is under facility supervision. This requirement was not met as evidenced by:
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Licensee to conduct staff training on Title 22 reporting requirements and submit training record to CCLD by POC due date.
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Based on staff interview & records review, the facility did not submit a written incident report to CCLD within 7 days of R1's 11/06/2019 & 12/16/2020 fall incidents with injuries that required treatment at a hospital. This posed a potential risk to the health & safety of R1.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021
LIC9099 (FAS) - (06/04)
Page: 8 of 9
Control Number 26-AS-20200929134214
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/06/2021
Section Cited
CCR
87207
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87207 FALSE CLAIMS. No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement was not met as evidenced by:
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Licensee to develop a written plan of action to correct deficiency and submit a copy of CCLD by POC due date.
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Based on interviews & records review, R1's 01/06/2020 ANS contained falsified signature of R1's RP. Additionally, R1's MAR show staff signs MAR daily to indicate R1's med was administered when another document showed R1 refused meds for 2 days. This posed a potential risk to the health of R1.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 9
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
09/29/2020 and conducted by Evaluator Ryker Heberle
COMPLAINT CONTROL NUMBER: 26-AS-20200929134214

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:58CENSUS: DATE:
07/29/2021
UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:TIME COMPLETED:
01:43 PM
ALLEGATION(S):
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Residents are being chemically restrained.
Unqualified staff administer medications to residents.
Resident's catheter was not removed by a trained professional.
Residents were not accorded dignity in relationships with staff.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ryker Heberle conducted a complaint visit today and met with Administrator, Erin Wiley, to deliver investigation findings.

On September 29, 2020, the Department received the above allegations against the facility and conducted an initial complaint investigation tele-visit on October 2, 2020 to conduct a tour of the facility, interview administrator and request facility records.

From November 19, 2020 through December 25, 2020, LPA conducted staff and resident interviews.

Continued, see LIC 9099-C, page 2 of 3.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 9
Control Number 26-AS-20200929134214
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: 07/29/2021
NARRATIVE
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5 out of 5 staff who were interviewed stated that they have not been asked by facility management to perform tasks beyond their qualifications including giving insulin injections and providing catheter care. 5 out of 5 staff stated that home health or hospice staff handle residents' care that require a trained medical professional such as catheter care. Facility staff only empties catheter bags.

5 out of 5 staff stated that only trained staff (S1-S3) dispense medications and they have not observed any residents being over medicated. 2 out of 2 staff who were interviewed were Medications Technicians and stated that they have completed medications training. 5 out of 5 residents who were interviewed stated that they do not receive insulin injections and they have not seen staff giving any resident injections.

5 out of 5 residents who were interviewed stated that staff assists them with their needs including their medications and they have not witnessed any staff not treating a resident with dignity.

LPA reviewed facility records. Staff training records in 2020 showed required medications training for staff (S1-S3) who were identified during interviews as staff who assist with residents' medications. Staff schedule from March 2020 to August 2020 was reviewed and showed at least one staff trained in medications on scheduled everyday.

The Department has investigated the above allegations. Based on interviews conducted and records reviewed, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegation did or did not occur.

Exit interview conducted with Administrator Erin Wiley. A copy of this report was provided during visit.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021
LIC9099 (FAS) - (06/04)
Page: 7 of 9
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
09/29/2020 and conducted by Evaluator Ryker Heberle
COMPLAINT CONTROL NUMBER: 26-AS-20200929134214

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:58CENSUS: DATE:
07/29/2021
UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:TIME COMPLETED:
01:43 PM
ALLEGATION(S):
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Facility is in disrepair.
Facility is not kept clean.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ryker Heberle conducted a complaint visit today and met with Administrator, Erin Wiley, to deliver investigation findings.

On September 29, 2020, the Department received the above allegations against the facility and conducted an initial complaint investigation tele-visit on October 2, 2020 to conduct a tour of the facility, interview administrator and request facility records.

From November 19, 2020 through December 25, 2020, LPA conducted staff and resident interviews.

Continued, see LIC 9099-C, page 2 of 3.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 9
Control Number 26-AS-20200929134214
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: 07/29/2021
NARRATIVE
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A random selection of 5 staff and 5 residents were interviewed. All residents and staff who were interviewed stated that they have not observed any unsafe and unsanitary conditions in the facility since working or living there. Residents and staff stated that the facility has a regular housekeeping schedule and facility is quick to repair any facility damages.

On October 2, 2020, LPA conducted a facility tour and observed that the facility had repainted its interiors and updated their furniture in the main reception area. According to Administrator, the flooring has also been upgraded and more facility renovations are planned. LPA did not observe unsafe or unsanitary conditions during inspection.

On December 25, 2020, LPA randomly inspected 5 resident bedrooms during resident interviews. LPA did not observe any rotten food or soiled dishes in residents' rooms. Residents confirmed that staff is quick to collect any dirty dishes or unfinished food from their rooms.

LPA interviewed other stakeholders who visit the facility, including the Long Term Care Ombudsman (LTCO). LTCO stated they have not observed any unsafe or unsanitary conditions in the facility in any of their visits to the facility.

This Department has investigated these allegations. Based on interviews conducted and LPA's observation, the Department has found that these allegations are UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis.

Exit interview conducted with Administrator Erin Wiley. A copy of this report was provided during visit.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 9