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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 445202851
Report Date: 10/18/2024
Date Signed: 10/18/2024 02:22:36 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
04/05/2022 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20220405104013
FACILITY NAME:PARADISE ASSISTED CARE CORPFACILITY NUMBER:
445202851
ADMINISTRATOR:WILEY, ERIN ROSEFACILITY TYPE:
740
ADDRESS:2177 17TH AVETELEPHONE:
(831) 475-1386
CITY:SANTA CRUZSTATE: CAZIP CODE:
95062
CAPACITY:39CENSUS: 22DATE:
10/18/2024
UNANNOUNCEDTIME BEGAN:
09:27 AM
MET WITH:Lusanta KaiyomTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Resident care needs not being met
Residents left in bed unattended
Bathroom light fixture not working
INVESTIGATION FINDINGS:
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On 10/18/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Licensee, Lusanta Kaiyom and explained the purpose of today's visit.

Regarding the allegations of resident care needs not being met and residents left in bed unattended, Reporting Party (RP) observed R1 to be in soiled diaper, or no diaper, and the same clothes for 1 week, no shower. RP observed other residents lying in bed when RP normally sees them engaged in activities or visiting in the Hub room first floor. These residents use wheelchairs and are unable to get out of bed on their own. RP witnessed resident calling for help and no staff came. RP went and looked for staff. Resident is blind and unable to use a call button system or understand to use a pendant to call for assistance.

page 1 of 2
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024
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-20220405104013
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: 10/18/2024
NARRATIVE
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LPA was able to interview staff members (S1 & S2). S1 mentioned that they always check the residents every 2 hours, or if we pass by the rooms, we just check on them if there is anything they need. S2 also mentioned that they go around and check the residents if they need anything. Usually, every 2 hours and if some of them calls with the pendant. If we are aware of their incontinence, we also check more frequently. LPA was also able to interview 2 residents (R2 & R3). Both mentioned that they are well taken care of in the facility. R2 mentioned that staff is always there when R2 needs anything. When call button is pressed staff comes, and they assist in anything needed. R3 also stated that they (staff) always take care of R3 and has no issues. They always come when R3 needs help.

Regarding the allegation of bathroom light fixture not working, RP stated that bathroom light fixture is not working, or bulbs were burnt out.

LPA interviewed the administrator (AD1) and stated that there is a handy man during this time that has come every day to check if there are any thing that needs to be fixed.

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 allegations are UNSUBSTANTIATED.

Report is reviewed and copy is provided.

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SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024
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
04/05/2022 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20220405104013

FACILITY NAME:PARADISE ASSISTED CARE CORPFACILITY NUMBER:
445202851
ADMINISTRATOR:WILEY, ERIN ROSEFACILITY TYPE:
740
ADDRESS:2177 17TH AVETELEPHONE:
(831) 475-1386
CITY:SANTA CRUZSTATE: CAZIP CODE:
95062
CAPACITY:39CENSUS: 22DATE:
10/18/2024
UNANNOUNCEDTIME BEGAN:
09:27 AM
MET WITH:Lusanta KaiyomTIME COMPLETED:
02:45 PM
ALLEGATION(S):
1
2
3
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5
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8
9
No qualified Administrator on site
INVESTIGATION FINDINGS:
1
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3
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5
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9
10
11
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On 10/18/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Licensee, Lusanta Kaiyom and explained the purpose of today's visit.

Regarding the allegation of no qualified administrator on site, Reporting Party (RP) stated that there is no Qualified Administrator on Duty at the facility. No one has been identified as the administrator.

Based on records review, the facility has a qualified administrator namely the Licensee. Administrator Certificate provided has qualification date of 8/9/2021 to 8/8/2023.

Based on records review, the department has determined that that the allegation was false, could not have happened and/or is without a reasonable basis, therefore the allegation is 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: 10/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024
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