445202559-11-12-2021-26-AS-KHOS-C9JJSC-20211209061807

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445202559
Report Date: 11/12/2021
Date Signed: 11/12/2021 05:13:25 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
06/22/2021 and conducted by Evaluator Ryker Heberle

COMPLAINT CONTROL NUMBER: 26-AS-20210622155359

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:	05:13 PM

ALLEGATION(S):

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Facility is understaffed
Unqualified staff assisting with medications

INVESTIGATION FINDINGS:

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

On June 22nd, 2021, the Department received the above allegation against the facility and conducted an initial complaint investigation visit on June 29th, 2021 to conduct a tour of the facility, interview staff and residents, and request facility records.

From June 29th, 2021 through, July 29th, 2021, LPA conducted staff and resident interviews. LPA interviewed 9 residents. 6 out of 9 felt that their needs were being met by the facility, while 2 stated that they were not, and 1 was unable to answer the question.

Substantiated

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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Control Number 26-AS-20210622155359

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: 11/12/2021

NARRATIVE

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During that same period, LPA interviewed 11 staff members. Of the staff members interviewed 11 out of 11 stated that they believed that the facility was understaffed. When asked about whether or not they believed they were able to meet all the residents needs during the course of their shift. 11 out of 11 staff indicated that they were able to complete all of their tasks, however 8 out of 11 stated that they had felt that other shifts were unable to complete all of their necessary tasks in a given day. Review of staff scheduling indicated multiple days where there was only 1 caregiver assigned for both evening and night shift.

During interviews with staff, 6 non-medical technician staff members stated that they had passed out medication while working at the facility. When asked about whether or not they had received training in passing out medication to residents, all 6 staff members stated that they had not. Review of staff training logs provided by administrator did not contain any documentation signed by facility staff indicating completion or attendance of training seminars regarding the passing of medication to residents.

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.

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

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20210622155359

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: 11/12/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/13/2021 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee to submit written plan of action to CCLD by POC due date.
	8 9 10 11 12 13 14	Based on LPAs interviews with residents and staff, facility does not have enough staff necessary to assist residents with care in a timely manner. This poses a potential risk to the health and safety of residents in care	8 9 10 11 12 13 14
Type B 11/19/2021 Section Cited CCR 87411(d)(4)	1 2 3 4 5 6 7	87411 Personnel Requirements - General (d) All personnel shall be given on the job training or have related experience in the job assigned to them... (4) Knowledge required to safely assist with prescribed medications which are self-administered.This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee to submit records of staff attendence to medication trainings offered at facility and/or a written to conducts in the future to CCLD by POC due date.
	8 9 10 11 12 13 14	Based on staff interviews and records received by CCLD, the faciliy did not provide medical training to 6 non-med tech staff who assisted with passing medications to residents. This poses a potential risk to the health and safety of residents in care	8 9 10 11 12 13 14

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 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 appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021

LIC9099 (FAS) - (06/04)

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