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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486800368
Report Date: 12/05/2024
Date Signed: 12/05/2024 12:00:53 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/19/2024 and conducted by Evaluator Julie Florio
COMPLAINT CONTROL NUMBER: 21-AS-20240919154700
FACILITY NAME:PARADISE VALLEY ESTATESFACILITY NUMBER:
486800368
ADMINISTRATOR:YEE, KELLYFACILITY TYPE:
741
ADDRESS:2600 ESTATES DRIVETELEPHONE:
(707) 432-1100
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:743CENSUS: 68DATE:
12/05/2024
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Kelly Yee, Administrator/Assisted Living ManagerTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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9
Questionable Death
INVESTIGATION FINDINGS:
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On 12/5/2024, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to delivered findings for the above allegation. LPA conducted 10-day on 9/20/2024 and obtained records and made observations. The complainant alleges that Resident 1 (R1) was not given a medication for nine days resulting in R1’s death.

The Department reviewed records, conducted interviews with outside medical professional, obtained medical records and death certificate. R1 moved into the facility on 8/31/2024 and on 9/9/2024 R1 was transported to the hospital due to an observed medical emergency. The Department received a self-reported incident report (9/12/2024) informing that there was an error with R1s medication at intake resulting in R1 not receiving a medication for nine days. R1 passed away on 9/15/2024 after being admitted to hospice.

Continued on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Julie FlorioTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
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 5
Control Number 21-AS-20240919154700
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: PARADISE VALLEY ESTATES
FACILITY NUMBER: 486800368
VISIT DATE: 12/05/2024
NARRATIVE
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Continued from LIC9099...

Interview with doctor overseeing R1s care revealed that due to R1s medical diagnosis and medical history they are unable to confirm that R1s death was a result of medication mismanagement. The medication that was not administered for nine days is prescribed to reduce the risk of blood clot; however, that risk does not completely go away by taking the medication. The death certificate was obtained and did not reveal evidence to support R1s death was a result of medication mismanagement.

Although this allegation may be true, based upon the statements made, documents reviewed, as well as site visit observations, there is not a preponderance of evidence to prove the allegation is or, is not, true. Therefore, the allegation is UNSUBSTANTIATED.

Exit interview conducted with Administrator, whose signature on form confirms receipt of documents.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Julie FlorioTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/19/2024 and conducted by Evaluator Julie Florio
COMPLAINT CONTROL NUMBER: 21-AS-20240919154700

FACILITY NAME:PARADISE VALLEY ESTATESFACILITY NUMBER:
486800368
ADMINISTRATOR:YEE, KELLYFACILITY TYPE:
741
ADDRESS:2600 ESTATES DRIVETELEPHONE:
(707) 432-1100
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:743CENSUS: DATE:
12/05/2024
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Kelly Yee, Administrator/Assisted Living ManagerTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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2
3
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5
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9
Staff mismanaged resident medication.
INVESTIGATION FINDINGS:
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On 12/5/2024, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to deliver findings for he above allegation. LPA conducted 10-day on 9/20/2024 and obtained records and made observations. The complainant alleges that resident R1 was not given a prescribed medication for nine days.

The Department reviewed records, conducted interviews with outside medical professional, obtained medical records and death certificate. R1 moved into the facility on 8/31/2024 and on 9/9/2024 R1 was transported to the hospital due to an observed medical emergency. On 9/12/2024 the Department received a self-reported incident report informing that there was an error with R1s medication at intake resulting in R1 not receiving a medication for nine days. The allegation of staff mismanaged resident medication is SUBSTANTIATED.

Continued on LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Julie FlorioTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20240919154700
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: PARADISE VALLEY ESTATES
FACILITY NUMBER: 486800368
VISIT DATE: 12/05/2024
NARRATIVE
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Continued from LIC9099A...

A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiency cited per Title 22 Regulations, Division 6, (See LIC9099D).

Exit interview conducted with Administrator, whose signature on form confirms receipt of documents. Appeal rights provided.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Julie FlorioTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20240919154700
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: PARADISE VALLEY ESTATES
FACILITY NUMBER: 486800368
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/06/2024
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care ....
(4)The licensee shall assist residents with self administered medications as needed.

This regulation was not met as evidenced by:
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Licensee conducted medication training on the importance of proper and accurate medication documentation and anticoagulant therapy. Additionally, facility has updated their policy regarding the reconciliation of medications and conducted an in person training on this updated policy.
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Licensee failed to ensure that all of R1's medications were properly documented upon the intake which led to one medication being left off of R1's daily medication administration record and the medication not being given for 9 days.
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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: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Julie FlorioTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5