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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 445202851
Report Date: 08/16/2024
Date Signed: 08/16/2024 04:52:48 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/22/2023 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20231122171044
FACILITY NAME:PARADISE ASSISTED CARE CORPFACILITY NUMBER:
445202851
ADMINISTRATOR:CHRISTINA RIVASFACILITY TYPE:
740
ADDRESS:2177 17TH AVETELEPHONE:
(831) 475-1386
CITY:SANTA CRUZSTATE: CAZIP CODE:
95062
CAPACITY:39CENSUS: 22DATE:
08/16/2024
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Lusanta KaiyomTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Facility staff caused multiple bruises to residents in care.
INVESTIGATION FINDINGS:
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On 8/16/2024, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Licensees Lusanta & Saaj Kaiyom and explained the purpose of today's visit.

Regarding the allegation of facility staff caused multiple bruises to residents in care. Reporting party (RP) stated that a resident (R1) disclosed on 10/13/2023 that the night staff have been hitting him/her. Per RP, when R1 was examined, R1 was observed to have bruising from one side of the chest to the other.

LPA Dolores interviewed two staff members. S1 mentioned that on 10/10/23, was when NOC shift found R1 on the floor. R1s chest was bruised and it was the front area. Hospice came to check and was aware of the fall. Family was called. Hospice thinks R1s rib broke. They talked to the responisble party (F1) and made the decision not to send R1 out. R1 wasn’t sent to the hospital after the fall. Another staff, S2 mentioned that R1 has a history in falling and transferring on his/her own. In the middle of the night R1 will try to get out of bed himself/herself.

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Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024
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-20231122171044
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
,
, CA
FACILITY NAME: PARADISE ASSISTED CARE CORP
FACILITY NUMBER: 445202851
VISIT DATE: 08/16/2024
NARRATIVE
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Last month (October 2023) R1 was completely bed bound. R1 would try to transfer himself/herself. Often time R1 would slide off the floor and call for help. R1 would be in that situation and would be off the floor or in between bed and wheelchair.

Based on records review, LPA Donato found out that part of R1s behavior is yelling and would keep on trying to get up on his/her own even though it is indicated in the needs and services plan that assistance is needed in providing activities of daily living (ADLs).

Based on interviews & records review, the department has determined that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Report is reviewed and copy is provided.

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SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2