<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 445202851
Report Date: 10/03/2024
Date Signed: 10/03/2024 02:05:36 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 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
04/27/2023 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20230427141045
FACILITY NAME:PARADISE ASSISTED CARE CORPFACILITY NUMBER:
445202851
ADMINISTRATOR:CHRISTINA RIVASFACILITY TYPE:
740
ADDRESS:2177 17TH AVETELEPHONE:
(831) 475-1386
CITY:SANTA CRUZSTATE: CAZIP CODE:
95062
CAPACITY:39CENSUS: 22DATE:
10/03/2024
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Lusanta & Saaj KaiyomTIME COMPLETED:
02:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff handles resident in a rough manner.
Staff barricaded resident's door.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 10/3/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Licensees, Lusanta & Saaj Kaiyom and explained the purpose of today's visit.

Regarding the allegation of staff handles resident in a rough manner, Reporting party (RP) reported that in January of 2022, RP was visiting R1 when it was observed that a caregiver was being rough with R1 while trying to transfer R1 to the wheelchair.

LPA Heberle tried contacting the number provided by RP but it was the wrong number. There is also no other information provided or description describing who the caregiver was.

con't...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
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 26-AS-20230427141045
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: PARADISE ASSISTED CARE CORP
FACILITY NUMBER: 445202851
VISIT DATE: 10/03/2024
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
Regarding the allegation of staff barricaded resident's door, RP stated that in early February 2022, RP observed R1 was barricaded by a recliner, moved in front of R1’s bedroom door so R1 could not get out.

LPA Donato interviewed Licensee, and it was mentioned that R1 was never barricaded in the room. R1 sometimes throws things at caregivers but no one has barricaded R1 in.

Based on interviews, the department has determined that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Report is reviewed and coy is provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 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
04/27/2023 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20230427141045

FACILITY NAME:PARADISE ASSISTED CARE CORPFACILITY NUMBER:
445202851
ADMINISTRATOR:CHRISTINA RIVASFACILITY TYPE:
740
ADDRESS:2177 17TH AVETELEPHONE:
(831) 475-1386
CITY:SANTA CRUZSTATE: CAZIP CODE:
95062
CAPACITY:39CENSUS: 22DATE:
10/03/2024
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Lusanta & KaiyomTIME COMPLETED:
02:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff not providing medication to resident as prescribed.
Unlawful eviction.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 10/3/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Licensees, Lusanta & Saaj Kaiyom and explained the purpose of today's visit.

Regarding the allegation of Facility staff not providing medication to resident as prescribed and unlawful eviction. RP stated that about mid-January of 2022, R2 had to be hospitalized, because R2 was not acting like himself/herself and was not being provided her medications for several days. RP also reported when R2 was ready to be discharged on 1/17/2022 the facility refused to take him/her back.

LPA interviewed Licensee and it was mentioned that R2 was never a resident of the facility. There are no admissions agreement signed.

Based on interviews, the department has determined that that the allegations were false, could not have happened and/or is without a reasonable basis, therefore the allegations are UNFOUNDED.

Report is reviewed and copy is provided.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3