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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800368
Report Date: 09/17/2024
Date Signed: 09/17/2024 10:19:49 AM


Document Has Been Signed on 09/17/2024 10:19 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 ESTATESFACILITY NUMBER:
486800368
ADMINISTRATOR:YEE, KELLYFACILITY TYPE:
741
ADDRESS:2600 ESTATES DRIVETELEPHONE:
(707) 432-1100
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:743CENSUS: DATE:
09/17/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Kelly Yee, Assisted Living ManagerTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Julie Florio arrived to the assisted living building in this Continuing Care Retirement Community (CCRC) unannounced to conduct a required 24-hour Case Management - Incident visit regarding an Unusual Incident Report (UIR), received by CCL on 9/12/2024. The UIR stated a Resident (R1) did not receive their Warfarin for nine (9) days, became unresponsive on 9/9/2024, was sent to the ER, and was then transferred to UC Davis Medical Center (UCDMC). Upon telephone follow up and email communications with Kelly Yee, Assisted Living Manager, on Monday, September 16, 2024, LPA was informed the R1 passed away on Sunday, September 15, 2024 at 8:00 PM at UCDMC.

Today, 9/17/2024, LPA met with Kelly Yee, Assisted Living Manager, and obtained documents, to include R1's admissions agreement and Death Report, not already received by CCL. Kelly states the facility is still waiting on R1's medical records and death certificate but will submit them to CCL upon receipt. A cause of death is still unknown by the facility at this time.

At approximately 9:45 AM, Kevin Hogan, Health Care Administrator arrived and stated he "would like to be a part of this" investigation.

No Deficiencies cited during visit.

Exit interview conducted. Copy of report discussed and provided to Manager. 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: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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