486803635-6-28-2022-21-AS-HDBI-CGFUFM-20220718153258

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803635
Report Date: 06/28/2022
Date Signed: 06/28/2022 05:08:39 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/23/2022 and conducted by Evaluator Karina Canela

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20220323095522

FACILITY NAME:	PARADISE HOME		FACILITY NUMBER:	486803635
ADMINISTRATOR:	TAGUPA, MARIA CARLA		FACILITY TYPE:	735
ADDRESS:	3809 POPPY HILL COURT		TELEPHONE:	(650) 387-9488
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94533
CAPACITY:	4	CENSUS: 4	DATE:	06/28/2022
		UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Ana Morales, Lead Staff/DSP		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff physically abused client

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Karina Canela arrived unannounced at Paradise Home to deliver findings on complaint # 21 AS-20220323095522. LPA met with Ana Morales, Lead Staff/DSP. Maria Carla Tagupa is no longer the administrator at Paradise Home since June 2021.

LPA investigated the above allegation of "Staff physically abused client". During the investigation, LPA requested and obtained copies of facility documents, conducted interviews, and made observations. It was reported that staff (S1) physically abused clients (C1 & C2).

Report continued on LIC9099-C...

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022

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 3

Control Number 21-AS-20220323095522

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: PARADISE HOME	FACILITY NUMBER: 486803635
	VISIT DATE: 06/28/2022

NARRATIVE

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The following was reported to the Santa Rosa Regional Office:
Community Care Licensing (CCL) received 2 Special Incident Reports (SIRs) and Report of Suspected Abuse (SOC341) reported on 03/11/2022 regarding Clients (C1 & C2). On 03/10/2022, licensee was notified by staff of unknown marking abrasions observed on C1's body and that they suspected S1 caused it. Licensee immediately contacted local Law Enforcement and Licensee took C1 to the emergency room on 03/10/2022 to be evaluated. C1 was discharged the same day within a few hours and discharge paperwork did not reveal what may have caused the "two-dot like marking's" on C1's abdomen, lower right thigh and arm. Staff interviews indicated S1 was previously observed "teasing" C1, which would at times aggravate C1. Staff interviews revealed S1 was observed on 03/09/2022 teasing and provoking C1 and a buzzing noise was heard but staff did not see or determine what was used on C1 to cause the small two-dot marking's.
On 03/11/2022, Licensee checked all other residents and discovered Client (C2) has similar marking abrasions on their back and arms like C1. C2 was taken to the emergency room to be checked and was discharged the same day. C2's attending medical physician determined the back abrasions were consistent with C2's back acne and were at different stages of healing but could not determine the cause of the arm abrasions.
Staff statements revealed S1 was observed "teasing and provoking" client (C1) and later observed with a hand held object that made a buzzing noise on C1 and possibly C2, causing small (less than a quarter of the size of a penny) 2-dot marking's. C1 was reportedly heard saying "no" to S1.
Licensee reported to CCL, North Bay Regional Center (NBRC), local law enforcement, and sought timely medical services within 24 hours. On 03/15/2022 Licensee conducted an all staff training on Standards of Conduct covering the facility's policies and sanctions for carrying or having weapons within the facility and surroundings. On 03/28/2022, licensee submitted documentation to CCL. Additionally, Licensee immediately removed S1 from the facility and S1 is no longer working at Paradise Home.
Based on observations, records reviewed, and interviews conducted, the licensee did not ensure clients were free from unusual punishment from staff (S1). The preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Appeal Rights Provided.

Deficiencies cited (see LIC809-D page) from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.
Exit interview conducted with Ana Morales, lead DSP, whose signature below confirms receipt of report.

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20220323095522

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: PARADISE HOME	FACILITY NUMBER: 486803635
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/28/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/29/2022 Section Cited CCR 80072(a)(3)	1 2 3 4 5 6 7	80072 Personal Rights: (a)…each client shall have personal rights which include, ....(3)To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature... **This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee immediately removed S1 from the facility and on 03/15/2022 conducted an all staff training regarding the incident (submitted documentation to CCL on 03/28/2022.
	8 9 10 11 12 13 14	Based on record review, interviews conducted and observations, licensee did not ensure the regulation above due to staff (S1) who inflicted pain onto C1 & C2. This is an immediate health, safety, and personal rights risk to clients in care.	8 9 10 11 12 13 14	The citation was cleared during this inspection.
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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.

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022

LIC9099 (FAS) - (06/04)

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