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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 445202559
Report Date: 11/12/2021
Date Signed: 11/12/2021 05:16:26 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
07/09/2021 and conducted by Evaluator Ryker Heberle
COMPLAINT CONTROL NUMBER: 26-AS-20210709154938
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: 30DATE:
11/12/2021
UNANNOUNCEDTIME BEGAN:
02:12 PM
MET WITH:Erin WileyTIME COMPLETED:
05:16 PM
ALLEGATION(S):
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9
Facility is not clean and sanitary
Facility is in disrepair
Insufficient staffing to meet residents' needs
Facility overcharged resident for services
Facility did not provide resident with clean linens
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 July 9th, 2021, the Department received the above allegations against the facility and conducted an initial complaint investigation visit on July 19th, 2021 to conduct a tour of the facility, interview administrator and request facility records.

During tour of the facility conducted on July 19th 2021, LPA observed chairs soiled with dried feces in the patio area of the facility. When LPA asked staff why the chairs were on the patio and whether they were going to be cleaned, staff stated that there was a plan to discard the chairs, but that they were not sure whether or not pickup has been scheduled.
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: 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)
Page: 1 of 7
Control Number 26-AS-20210709154938
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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Chairs with feces were again observed by LPA at the facility during inspection that occurred on July 29th 2021. During inspection on August 26th, 2021, chairs were noted to no longer be at the facility.

During inspection on July 19th 2021, LPA observed sliding screen door of resident room fraying apart from the frame, with tears near the door handle. Screen door was also noted to be difficult to open.

LPA conducted review of facility admissions agreement. Admissions agreement indicates that family members must receive a 60 day written notice of rate change, along with reasons for rate change, prior to adjusting resident rates. LPA reviewed invoice statements of 1 resident with rate changes. Review of resident file did not indicate any written correspondence indicating the reason for raising resident rates.

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. 6 out of 11 staff members interviewed stated that they had arrived to discover residents left in soiled sheets or clothes upon beginning their shift, but were unable to determine how long residents had been left. 1 out of 3 family members interviewed stated that they had arrived to find their loved ones in soiled clothes or sheets. Review of staff schedule indicated multiple days in which 1 caregiver was scheduled to work the evening shift, and 1 caregiver was scheduled to work the night shift.

The Department has conducted an investigation of the above allegations. Based on LPA observation, 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 YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 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)
Page: 2 of 7
Control Number 26-AS-20210709154938
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 B
11/19/2021
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation - (a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidenced by:
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Deficinecy observed to have been corrected. Licensee to submit written plan of action to CCLD by POC due date.
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Based on observation, the facility did not properly dispose of or clean furniture soiled with feces. This posed a potential risk to the health and safety residents in care.
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Type B
11/19/2021
Section Cited
CCR
87303(c)
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87303 Maintenance and Operation - (c) All window screens shall be clean and maintained in good repair. This requirement was not met as evidenced by:
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Licensee to submit written plan to fix sliding screen door or receipt of bill of sale to CCLD by POC due date.
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Based on observation, the facility did not repair or replace damaged sliding glass door screen. This posed a potential risk to the health and safety of residents in care
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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: 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)
Page: 3 of 7
Control Number 26-AS-20210709154938
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 B
11/19/2021
Section Cited
CCR
87505(f)
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87505 Admission Agreements - (f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement was not met as evidenced by:
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Licensee shall provide facility plan to ensure timely communication between facility and responsible parties regarding raising of rates to The Department by POC due date.
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Based on records review, the facility did not provide written notice to a resident's responsible party 60 days prior to raising resident rates. This posed a potential risk to the health and safety residents in care.
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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: 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)
Page: 4 of 7
Control Number 26-AS-20210709154938
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)
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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:
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Licensee to submit written plan of action to CCLD by POC due date.
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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 an immediate risk to the health and safety of residents in care
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Type A
11/13/2021
Section Cited
CCR
87464(f)(4)
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87464 - Basic Services - (f) Basic services shall at a minimum include... (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications... This requirement was not met as evidenced by:
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Licensee to submit written plan of action to CCLD by POC due date.
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Based on interviews and records reviewed, residents had been observed by staff and visitors to be in wet/soiled sheets or clothes, which poses an immediate health risk to residents in care.
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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: 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)
Page: 5 of 7
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
07/09/2021 and conducted by Evaluator Ryker Heberle
COMPLAINT CONTROL NUMBER: 26-AS-20210709154938

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:
11/12/2021
UNANNOUNCEDTIME BEGAN:
02:12 PM
MET WITH:TIME COMPLETED:
05:16 PM
ALLEGATION(S):
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2
3
4
5
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7
8
9
Facility did not safeguard resident's personal property
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 July 9th, 2021, the Department received the above allegations against the facility and conducted an initial complaint investigation visit on July 19th, 2021 to conduct a tour of the facility, interview administrator and request facility records.

In review of facility admission agreements, 0 out of 4 admissions agreements indicated that residents opted to have a personal inventory taken of their possessions. In interviews with facility residents, 0 out of 9 residents indicated that they had never had possessions go missing during stay at the facility. 0 out of 3 visiting family members interviewed indicated that they had possessions go missing at the facility.
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: 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)
Page: 6 of 7
Control Number 26-AS-20210709154938
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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This Department has investigated the above allegation. Based on interviews, observations, and records review, the Department found that the above allegation is 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.

This report was reviewed with Administrator and a copy of this report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 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)
Page: 7 of 7