445202851-5-16-2024-26-AS-RMAO-D5QPPM-20240529112942

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445202851
Report Date: 05/16/2024
Date Signed: 05/16/2024 04:03:40 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 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
02/20/2024 and conducted by Evaluator Simranjit Rai

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20240220124121

FACILITY NAME:	PARADISE ASSISTED CARE CORP		FACILITY NUMBER:	445202851
ADMINISTRATOR:	CHRISTINA RIVAS		FACILITY TYPE:	740
ADDRESS:	2177 17TH AVE		TELEPHONE:	(831) 475-1386
CITY:	SANTA CRUZ	STATE: CA	ZIP CODE:	95062
CAPACITY:	39	CENSUS: 22	DATE:	05/16/2024
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Licensee/Administrator, Saaj Kaiyom & Licensee, Lustana Kaiyom		TIME COMPLETED:	04:10 PM

ALLEGATION(S):

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Staff does not allow resident to exercise.
Staff forced resident to be wiped.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with the Licensee/Administrator, Saaj Kaiyom & Licensee, Lustana Kaiyom and stated the purpose of today’s visit.

On 2/20/2024, the Department received a complaint with the above allegations. On 2/22/2024, the Department conducted an initial investigation at the facility.

Continuaton on LIC 9099-C, Page 1 of 3.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024

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 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 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
02/20/2024 and conducted by Evaluator Simranjit Rai

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20240220124121

FACILITY NAME:	PARADISE ASSISTED CARE CORP		FACILITY NUMBER:	445202851
ADMINISTRATOR:	CHRISTINA RIVAS		FACILITY TYPE:	740
ADDRESS:	2177 17TH AVE		TELEPHONE:	(831) 475-1386
CITY:	SANTA CRUZ	STATE: CA	ZIP CODE:	95062
CAPACITY:	39	CENSUS: 22	DATE:	05/16/2024
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Licensee/Administrator, Saaj Kaiyom & Licensee, Lustana Kaiyom		TIME COMPLETED:	04:10 PM

ALLEGATION(S):

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Resident sustained UTI while in care.
Staff did not assist resident in a timely manner.
Staff does not responding to resident’s call button.

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 26-AS-20240220124121

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: PARADISE ASSISTED CARE CORP	FACILITY NUMBER: 445202851
	VISIT DATE: 05/16/2024

NARRATIVE

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Page 2 of 3.
Resident sustained UTI while in care.
It was alleged a female resident has not sustained rashes but sustained a UTI.

On 2/22/2024, the Department interviewed ADM. ADM stated the resident are given water and the staff will remind residents to drink water, however the staff cannot force the residents to drink water. ADM stated one resident (R1) has a history of UTI and doctor has prescribed antibiotics for prevention.

On 2/22/2024, the Department interviewed S1. S1 stated R1 has a chronic UTI and is always on medication. Per S1, facility staff during morning shift provide routine incontinence care at approximately 6am, 8am, between 9-9:30am, 12pm, between 1-1:30pm.

On 5/16/2024, LPA Rai interviewed 10 residents. 4 Out of 10 residents refused the interview. 6 Out of 10 residents agreed to the interview. 6 Out of 6 residents stated they did not sustain UTI while in care. 2 Out of 6 residents stated they are concerned about UTI so they ensure they are drinking enough water. 6 Out of 6 residents stated the facility staff bring them water and ensure water is available in the rooms. During interview, LPA Rai observed either cups of water or a water bottle filled with water assessable to the resident. 6 Out of 6 residents have not heard about residents sustaining UTI while in care.

Based on record review, R1 moved into the facility on 1/11/2022. Per R1’s Physician’s Report dated 1/10/2022 and 3/7/2024, R1 has a secondary diagnosis of urinary Tract Infection. Based on record review of R1’s Physician’s Order for UTI medication and Physician’s Note dated 2/26/2024 for R1, R1 continue to have recurrent UTI and R1 was administered 2 different antibiotics for UTI on 3/12/2024.

Staff did not assist resident in a timely manner/ Staff does not respond to resident’s call button.
It was alleged when the resident requests to be toileted, it takes one hour for the staff member to come and assist. It was alleged when the resident presses the call button for assistance the staff member(s) does not respond or come assist.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 26-AS-20240220124121

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: PARADISE ASSISTED CARE CORP	FACILITY NUMBER: 445202851
	VISIT DATE: 05/16/2024

NARRATIVE

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Page 3 of 3.
On 2/22/2024, the Department interviewed ADM. ADM stated he is not aware of this issue but if there are multiple people requiring assistance, then there is a cue for when staff will respond. The facility does have a call bell system for the residents to press a button to request for help.

On 2/22/2024, the Department interviewed staff (S1). S1 stated there are times where multiple residents do request for help at the same time. S1 stated the residents do not wait for more than 20 minutes but the call bell system does not allow for them to check how long the resident has been waiting. S1 stated there are always 4 staff in the facility during AM shift and PM shift and 2 staff present during night shift. S1 stated the staff use the walkie talkie to communicate their location and which resident they are assisting. S1 stated the pager will notify when the resident has requested for help with the pendent.

On 2/22/2024, LPA Rai observed the call bell system, but the system does not log the calls, so LPA Rai was not able to review the call bell system for previous requests. During visit, LPA Rai observed the pendent being used by 5 different residents and the pendants were cleared within 5 minutes.

On 5/16/2024, LPA Rai interviewed 10 residents. 4 Out of 10 residents refused the interview. 6 Out of 10 residents agreed to the interview. 6 out of 6 residents use the call button to request for staff assistance. 6 Out of 6 residents stated it will take 5-10 minutes before staff will respond to the request. 5 Out of 6 residents stated they did not have any issues with the staff responding in a timely manner. 5 Out of 6 residents stated they cannot recall a time when the facility staff took more than 20 minutes to answer their call button. During one of the interviews, LPA Rai observed 1 resident press the call pendent and the staff checked the resident within 3 minutes.

Based on the interviews conducted with clients and staff and based on observation and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Licensee/Administrator, Saaj Kaiyom & Licensee, Lustana Kaiyom and a copy of the report was provided.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 26-AS-20240220124121

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: PARADISE ASSISTED CARE CORP	FACILITY NUMBER: 445202851
	VISIT DATE: 05/16/2024

NARRATIVE

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Page 2 of 3.
Staff does not allow resident to exercise.
It was alleged a resident was not allowed to exercise in the bed since the resident stays in bed.

On 2/22/2024, the Department interviewed ADM. ADM stated the facility does provide exercise activities twice a week but not all the residents have the physically capabilities to do the exercise. ADM stated there is a resident (R1) who wants to do exercises in bed, but R1 would like the staff to do physical therapy exercises and the facility staff are not trained to provide those exercises. ADM stated R1 has been referred to physical therapy sessions and allowed for private caregiver to come in and provide the physical therapy exercises requested. ADM stated R1 attends physical therapy at outside clinic.

On 2/22/2024, the Department interviewed staff (S1). S1 stated the facility does provide exercise twice a week. S1 stated R1 is very particular about exercise and R1 would like the staff to do exercise in the bed. S1 stated the NOC shift staff will help R1 be in butterfly yoga position.

Based on review of facility’s calendar from November 2023 – February 2024, which stated the facility provides exercise twice a week. Based on R1’s Progress notes, on 8/5/2023, R1’s Physical Therapist suggested R1 to stay upright without support and R1 requested for facility staff to be on standby in the room for breakfast while R1 was upright in bed.

On 5/16/2024, LPA Rai interviewed 10 residents. 4 Out of 10 residents refused the interview. 6 Out of 10 residents agreed to the interview. 6 Out of 6 residents stated they are aware the facility has exercise as one of the activities but has not heard of staff doing exercises in the resident’s room. They stated staff do not restrict them to exercise. 3 Out of 6 residents participate in the activities at the facility and have attended the exercise activity and they have no issues or concerns about the exercise activity. 1 Out of 6 resident stated the facility staff encourage him/her to walk.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 26-AS-20240220124121

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: PARADISE ASSISTED CARE CORP	FACILITY NUMBER: 445202851
	VISIT DATE: 05/16/2024

NARRATIVE

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Page 3 of 3.
Staff forced resident to be wiped.
It was alleged the resident requested to be wiped with soap and water with a paper towel and facility staff forcefully wipes the resident with an “anti-bacterial” wipe.

On 2/22/2024, the Department interviewed the ADM. ADM stated the staff do not use “anti-bacterial” wipe but baby wipes which are intended for incontinence use. ADM stated R1 wants to use Bounty paper towels, but the towels are not intended for incontinence use and may be rough over the skin. ADM stated the facility staff have advised R1 about the roughness again the skin.

On 2/22/2024, the Department interviewed the staff (S1). S1 stated the facility staff does not use antibacterial wipe but the staff use baby wipes which are for incontinence care. S1 stated R1 prefers to use wet Bounty paper towels for incontinence use. S1 stated R1 has vocalized not to use baby wipes and the staff no longer use them for R1.

On 5/16/2024, LPA Rai interviewed 10 residents. 4 Out of 10 residents refused the interview. 6 Out of 10 residents agreed to the interview. 6 Out of 6 residents stated they receive incontinence care, and they receive assistance from the facility staff. 6 Out of 6 residents stated the facility staff will use wet wipes to clean the private area. 6 Out of 6 residents stated they have not seen or heard staff using antibacterial wipes on the resident in the private area. During the interviews, LPA Rai observed wet wipes for incontinence use in the resident’s room and did not observe anti-bacterial wipes in the rooms.

The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Licensee/Administrator, Saaj Kaiyom & Licensee, Lustana Kaiyom and a copy of the report was provided.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024

LIC9099 (FAS) - (06/04)

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