445202559-11-12-2021-26-AS-KHOS-C9JLKU-20211209075006

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445202559
Report Date: 11/12/2021
Date Signed: 11/12/2021 05:19:33 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
07/23/2021 and conducted by Evaluator Ryker Heberle

COMPLAINT CONTROL NUMBER: 26-AS-20210723170636

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: 30	DATE:	11/12/2021
		UNANNOUNCED	TIME BEGAN:	02:12 PM
MET WITH:	Erin Wiley		TIME COMPLETED:	05:23 PM

ALLEGATION(S):

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Facility did not provide a admission agreement to resident's responsible party

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ryker Heberle conducted an unannounced complaint visit and met with Administrator, Erin Wiley, to deliver investigation findings.

On July 23rd, 2021, the Department received the above allegation against the facility and conducted an initial complaint investigation visit on July 29th, 2021 to tour the facility, interview staff and residents, and request facility records. LPA reviewed facility files for 3 residents to determine individuals with power of attorney privilege. During interview with resident power of attorney (POA), POA indicated that they had not requested resident admissions agreement and had never been denied documentation in the past.

This Department has investigated this allegation. Based on interviews conducted and records reviewed, the Department has found that this allegation is UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted with licensee/administrator. A copy of this report was provided electronically for signature.

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: 11/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021

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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