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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435200465
Report Date: 10/18/2023
Date Signed: 10/18/2023 05:06:22 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, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/21/2021 and conducted by Evaluator Chihhsien Chang
COMPLAINT CONTROL NUMBER: 26-AS-20211221115941
FACILITY NAME:PARADISE MANORFACILITY NUMBER:
435200465
ADMINISTRATOR:MIGUEL, LYNDAFACILITY TYPE:
740
ADDRESS:1645 PEACHWOOD DRIVETELEPHONE:
(408) 729-1539
CITY:SAN JOSESTATE: CAZIP CODE:
95132
CAPACITY:6CENSUS: 4DATE:
10/18/2023
UNANNOUNCEDTIME BEGAN:
03:50 PM
MET WITH:Melanie GavinaTIME COMPLETED:
04:39 PM
ALLEGATION(S):
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The facility bathroom has mold.
INVESTIGATION FINDINGS:
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LIcensing Program ANalyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the invstigation finding and met with House Manager (HM) Melanie Gavina.

On 12/21/2021, the Department received a complaint with the allegation that the facility bathroom has mold.

On 12/27/2021, LPA conducted an initial investigation visit, toured the facility, inspected the food supplies, and interviewed ADM, 3 staff (S1 - S3), and 6 residents (R1 - R6).



Continue on LIC9099-C. Page 1 of 2.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023
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 26-AS-20211221115941
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: PARADISE MANOR
FACILITY NUMBER: 435200465
VISIT DATE: 10/18/2023
NARRATIVE
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The facility bathroom has mold:

On 12/27/2021, LPA interviewed 6 residents (R1 - R6). 5 out of 6 stated the staff cleaned the bedrooms and restrooms every day. 2 out of 6 residents stated there was mold on the top of the restroom. LPA interviewed Administrator (ADM) Lynda Miguel. ADM stated the facility staff cleaned all the residents' bedrooms and bathrooms every day.

LPA toured the facility with S1 and ADM including the common area, 4 resident bedrooms and 3 restrooms. LPA found mold on the ceiling of one of the resident restrooms. LPA showed the mold on the ceiling of the restroom to S1. S1 agreed that it was mold. LPA showed the mold on the ceiling of the resident restroom, ADM admitted it was mold and stated the mold would be cleaned up by end of the day.

Based on the observation and interviews, mold was found on the ceiling of one of the resident restrooms, and S1 and ADM admitted it was mold.

The Department has investigated the above allegation. Based on observation, and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED.

Deficiencies are being cited. See LIC 9099-D.

Exit interview conducted with ADM. The report was provided to HM for signature. A copy of this report was provided to HM.

Page 2 of 2

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/21/2021 and conducted by Evaluator Chihhsien Chang
COMPLAINT CONTROL NUMBER: 26-AS-20211221115941

FACILITY NAME:PARADISE MANORFACILITY NUMBER:
435200465
ADMINISTRATOR:MIGUEL, LYNDAFACILITY TYPE:
740
ADDRESS:1645 PEACHWOOD DRIVETELEPHONE:
(408) 729-1539
CITY:SAN JOSESTATE: CAZIP CODE:
95132
CAPACITY:6CENSUS: 6DATE:
10/18/2023
UNANNOUNCEDTIME BEGAN:
03:50 PM
MET WITH:Melanie GavinaTIME COMPLETED:
04:39 PM
ALLEGATION(S):
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2
3
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5
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9
The facility does not serve food in good quality.
INVESTIGATION FINDINGS:
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LIcensing Program ANalyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the invstigation finding and met with House Manager (HM) Melanie Gavina.

On 12/21/2021, the Department received a complaint with the allegation that the facility does not serve food in good quality.

On 12/27/2021, LPA conducted an initial investigation visit, toured the facility, inspected the food supplies, and interviewed ADM, 3 staff (S1 - S3), and 6 residents (R1 - R6). The facility food menu was obtained.



Continue on LIC9099-C. Page 1 of 2.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 26-AS-20211221115941
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: PARADISE MANOR
FACILITY NUMBER: 435200465
VISIT DATE: 10/18/2023
NARRATIVE
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The facility does not serve food in good quality:
On 12/27/2021, LPA interviewed Administrator (ADM). ADM stated the facility provided the meals to residents based on the food menu. ADM stated he/she did the grocery shopping for the facility and he/she tried to shop for different food supplies to make the food meals with changes and varieties. ADM stated it was hard to make each resident fully satisfied. ADM denied the facility provided raw food, expired food or spoiled food to residents.

On the same day, LPA interviewed 3 staff. 3 out of 3 staff stated they all took turns to cook breakfast, lunch and dinner based on the menu. 3 out of 3 staff denied they provided raw food or expired food to residents. They all agreed that they provided sandwich for lunch.

LPA interviewed 6 residents (R1 - R6), 4 out of 6 residents (R1 - R4) stated the facility food is good. 1 out of 6 residents(R6) was unable to answer the question. 1 out of 6 residents (R5) stated the facility provided the chicken with blood inside and pink inside, he/she stated he/she can cook better than staff but was not allowed to cook. 2 out of 6 residents (R3. R4) stated the sandwich for lunch is fine but they prefer to have hot food for lunch.

LPA toured the facility with S1 to check the milk, perishable food and nonperishable food. LPA did not find expired milk or expired food. 2 day perishable food and 7 day nonperishable food were observed sufficient.

Based on reviewing the food menu, all the weekday lunches were sandwich and many meals were supplied with "low fat", "low calorie" food.

The Department has investigated the above allegation. Based on interview, record review, and observation the department has found the above allegation is unsubstantiated. An unsubstantiated finding indicates that although the allegation may have happened and/or is valid there is not a preponderance of evidence to show the alleged violations did or did not occur.

No deficiencies were cited per California Code of Regulations, Title 22.

This report was reviewed with HM and a copy of the report was provided.
Page 2 of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 26-AS-20211221115941
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: PARADISE MANOR
FACILITY NUMBER: 435200465
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/19/2023
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Administrator stated he/she will submit a plan of correction by the POC due date to prevent the similar incident to occur again.

LPA checked the bathroom today and there is no mold observed in the bathroom.
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This requirement was not met as evidenced by:
Based on the observvation, mold was observed on the ceiling of one of the restroom which posed a immediate health and safety risk to residents in care.
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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: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5