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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 05:09:37 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
05/19/2021 and conducted by Evaluator Ryker Heberle
COMPLAINT CONTROL NUMBER: 26-AS-20210519110514
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:
05:09 PM
ALLEGATION(S):
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Staff mismanaged resident's medication
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 05/19/2021, the Department received a complaint against the facility alleging mismanagement of residents medication. On 05/27/2021, the Department initiated an investigation of the above allegations. During records review, it was observed that in 1 out of 5 files, resident MARs did not indicate administration of all medications indicated on medicine lists. During audit of medicine cabinet conducted on 8/26/2021, 1 out of 3 resident medication supplies was noted to have an empty supply of a prescribed medication with no noted order for resupply. There was no discontinuation of medication orders noted for these medications not being administered as prescribed.

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.
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)
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Control Number 26-AS-20210519110514
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
11/15/2021
Section Cited
CCR
87465(c)(2)
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87465 - Incidental Medical and Dental Care - If the resident's physician has stated in writing that the resident is unable to determine his/her own need... licensee shall be permitted to assist the... provided all of the following requirements are met... (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by:
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Licensee to submit written plan for staff med training action as well as plan to implement physician's orders within 24 hours to CCLD by POC due date.
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Based on records review, 1 out of 1 resident MAR records did not match the doctor's orders - discontinued meds were sjown as still given and doctor's orders were not listed. This posed an immediate risk to the personal rights 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)
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