486800368-10-31-2024-21-AS-JFLO-DAKS4W-20241031133325

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486800368
Report Date: 10/31/2024
Date Signed: 10/31/2024 01:33:29 PM

Document Has Been Signed on 10/31/2024 01:33 PM - 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 ESTATES		FACILITY NUMBER:	486800368
ADMINISTRATOR/ DIRECTOR:	YEE, KELLY		FACILITY TYPE:	741
ADDRESS:	2600 ESTATES DRIVE		TELEPHONE:	(707) 432-1100
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94533
CAPACITY: 743	TOTAL ENROLLED CHILDREN: 0	CENSUS: 53	DATE:	10/31/2024
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:30 AM
MET WITH:	Kelly Yee, Administrator		TIME VISIT/ INSPECTION COMPLETED:	01:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 10/31/2024, at approximately 11:30 AM, Licensing Program Analyst (LPA) Julie Florio arrived to the Quail Creek Assisted Living building in this Continuing Care Retirement Community (CCRC) unannounced to conduct a Case Management - Incident visit regarding a Report of Suspected Dependent Adult/Elder Abuse form SOC341, received by CCL on 10/17/2024. LPA met with Kelly Yee, Assisted Living Manager (ALM), who over sees both of the community's assisted living buildings, and who informed LPA that Resident 1 (R1) resides in the Willow Creek Assisted Living building of the community. LPA gathered documentation and interviewed ALM before proceeding to the Willow Creek building to interview R1. The report, received by CCL on 10/17/2024, states R1 reported that Staff 1 (S1) "grabbed her 'because she didn't like what I said, and I have a bruise.' No bruise noted." Additionally, the report states that R1 "was unable to tell when incident occurred. Further, the report states that the responsible party, local law enforcement, and the Ombudsman were notified on 10/17/2024 as required. LPA followed up via telephone the same day and spoke with ALM. LPA requested ALM take photos of R1's arms if she would consent to it and send them to LPA. ALM later emailed LPA stating R1 refused having photos taken and when asked again when the incident occurred, ALM reported that R1 stated, "2 weeks to maybe a month ago. I really can't remember." Today, 10/31/2024, ALM provided LPA with notes regarding their interview with accused S1, which states S1 was unsure of any recent interaction except a time when they observed R1's spouse attempting to help transfer R1 and staff stated they were concerned about the spouses back and intervened to assist with the transfer. S1 stated that R1 became agitated and upset because they wanted their spouse to transfer them. ALM noted that S1 was instructed not to be alone with R1 and to always have another staff member present when interacting with R1 in their room. Continued on LIC809C...

Bethany Moellers	TELEPHONE: (707) 588-5040
Julie Florio	TELEPHONE: (707) 588-5026
	DATE: 10/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024

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

LIC809 (FAS) - (06/04)

Page: 1 of 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/31/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from LIC809...

Additionally, LPA obtained a copy of the police incident report, which states R1 declined police contact and interview, facility's interdisciplinary notes regarding R1's temperament, interactions, and conversations about the reported incident, including visit notes from a Social Services Counselor where R1 and their spouse reported no concerns. LPA also was informed that the social worker requested a Neurological/Psychiatric consultation which has already been conducted but facility has not received a copy the report yet, and the doctor who performed the visit is currently out of the country. R1's care plan dated 07/23/2024 states occasional memory loss.

LPA was unable to interview S1 due to S1 currently being out of work with COVID.

At approximately 1:00 PM, LPA proceeded to the Willow Creek Assisted Living building in the community with ALM to conduct interview with R1, who reported that the incident occurred about a month ago, and they did not report it, because "I was a chicken." R1 stated really liking S1 and does not think it was intentional. S1 reporting feeling that S1 was trying to be helpful. R1 provided conflicting statements and appeared confused. R1 had no concerns to report.

No Deficiencies cited during visit.

Exit interview conducted. Copy of report discussed and provided to ALM. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Julie Florio	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2