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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347004242
Report Date: 07/30/2021
Date Signed: 07/30/2021 10:43:56 AM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/09/2021 and conducted by Evaluator Melissa Lusby
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20210709080402
FACILITY NAME:A GARDEN OF PARADISE CARE HOMEFACILITY NUMBER:
347004242
ADMINISTRATOR:OKSANA DOLDIERFACILITY TYPE:
740
ADDRESS:7789 SPENCER LANETELEPHONE:
(916) 878-9811
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:6CENSUS: 5DATE:
07/30/2021
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Oksana DoldierTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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9
Staff hit resident in care
INVESTIGATION FINDINGS:
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LPA Lusby arrived on Friday July 30, 2021 to conclude a complaint investigation regarding the above allegation. Prior to the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask.

Throughout the course of the investigation, LPA interviewed staff, residents at the facility, relevant parties and reviewed R1's physician's report, hospital discharge paperwork, and needs and services plan. LPA learned that R1 has a diagnosis of Dementia and a history of hallucinations.
(Continued on LIC9099-C)
Unfounded
Estimated Days of Completion: 0
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Melissa Lusby
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021
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 2
Control Number 25-AS-20210709080402
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: A GARDEN OF PARADISE CARE HOME
FACILITY NUMBER: 347004242
VISIT DATE: 07/30/2021
NARRATIVE
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Based on LPA's interviews and review of documentation, the preponderance of evidence standards was not met, therefore, the above allegation is found to be UNFOUNDED. An unfounded allegation means that the allegation was false, could not have happened and/or is without a reasonable basis. LPA Lusby conducted an exit interview. A copy of this report was left at the facility.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Melissa Lusby
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2